Citation Nr: 1318580 Decision Date: 06/07/13 Archive Date: 06/11/13 DOCKET NO. 09-02 781 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to service connection for hyperactive parasympathetic syndrome (previously characterized as syncopal episodes). 2. Entitlement to an initial rating in excess of 20 percent for degenerative joint disease of the lumbar spine. 3. Entitlement to an initial rating in excess of 10 percent for residuals of anterior cruciate ligament (ACL) reconstruction of the right knee. 4. Entitlement to an initial rating in excess of 10 percent for chondromalacia of the left knee, status post arthroscopic debridement. 5. Entitlement to an initial rating in excess of 10 percent for osteoarthritis of the left hand and post-surgical residuals of left ulna fracture (previously characterized as osteoarthritis of the left hand). 6. Entitlement to an initial rating in excess of 30 percent for migraine headaches. 7. Entitlement to an initial rating in excess of 10 percent for degenerative changes of the right shoulder. 8. Entitlement to a total rating based upon individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Jeffrey E. Marion, Attorney WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD D.J. Drucker, Counsel INTRODUCTION The Veteran served in the Army Reserve National Guard and the United States Army Reserve, from October 1978 to January 2007, with periods of active and inactive duty, including verified active service in the United States Army and Army Reserve from May 1979 to May 1992 and from March 2002 to January 2007, respectively. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a May 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia. The decision, in pertinent part, granted service connection for migraine headaches, degenerative joint disease of the lumbar spine, right knee ACL disability, left knee chondromalacia, degenerative changes of the right shoulder and osteoarthritis of the left hand, each assigned initial 10 percent disability ratings, effective from February 1, 2007. The decision also denied service connection for an ulnar osteotomy of the left wrist and declined to reopen the Veteran's claim for service connection for hyperactive parasympathetic syndrome (previously characterized as syncopal episodes). He submitted a timely notice of disagreement as to the assigned disability evaluations and denial of his service connection claims. Then, in a September 2009 rating decision, the RO increased the evaluations for the Veteran's migraine headaches and lumbar spine disability to 30 percent and 20 percent, respectively, both effective February 1, 2007. In a March 2012 rating decision, the RO granted service connection for post surgical residuals of the left ulnar fracture on the basis of aggravation and recharacterized the Veteran's service-connected osteoarthritis of the left hand disability as osteoarthritis of the left hand and post surgical residuals of left ulna fracture. Thus, the two disorders were contemplated under one rating. In March 2013, the Veteran testified during a hearing before the undersigned Veterans Law Judge, conducted at the Board's main office in Washington, D.C. A transcript of the hearing is of record. With respect to the TDIU issue on appeal, during the course of the initial rating appeal for knee, lumbar spine, and wrist disabilities, the Veteran has also alleged unemployability due to his varied service-connected disabilities. See e.g., January 23, 2013 letter from Veteran's attorney at pages 2-3. See 38 C.F.R. § 3.156(b) (2012); Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009) (a request for a TDIU, whether expressly raised by Veteran or reasonably raised by the record, is not a separate "claim" for benefits, but rather, can be part and parcel of a claim for an initial rating for a disability). See also Norris v. West, 12 Vet. App. 413, 421 (1999); Roberson v. West, 251 F.3d 1378, 1384 (Fed. Cir. 2001). As such, entitlement to TDIU is also on appeal in the present case. The claim of service connection for syncopal episodes (now characterized as hyperactive parasympathetic syndrome) was denied by the RO in a February 1994 rating decision. New and material evidence or a notice of disagreement was not received within one year of the notice of this decision. Ordinarily new and material evidence would be required to reopen the claim. 38 U.S.C.A. §§ 5108, 7105(c) (West 2002); 38 C.F.R. § 3.156(a)-(b) (2012). However, after the February 1994 determination, the RO received relevant service treatment records that were not previously considered. These records were in existence at the time of the prior denial. VA adopted a regulation providing that when such records were received, the prior decision will be reconsidered without the requirement for new and material evidence. 38 C.F.R. § 3.156(c) (2012). The claim for service connection for hyperactive parasympathetic syndrome (previously characterized as syncopal episodes) is therefore being considered on a de novo basis. The issues of increased ratings for right and left knee, left hand and ulna, and lumbar spine disabilities, service connection for hyperactive parasympathetic syndrome, and entitlement to a 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. FINDING OF FACT On April 20, 2012, prior to the promulgation of a decision in the appeal, VA received notification from the appellant that a withdrawal of his appeal as to his claims for increased initial ratings for his service-connected migraine headaches and degenerative changes to the right shoulder is requested. CONCLUSION OF LAW The criteria for withdrawal of an appeal by the appellant as to his claims for increased initial ratings for his service-connected migraine headaches and degenerative changes to the right shoulder have been met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002); 38 C.F.R. § 20.204 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C.A. § 7105 (West 2002). An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 20.204 (2012). Withdrawal may be made by the appellant or by his authorized representative. 38 C.F.R. § 20.204. In the present case, the appellant has withdrawn his appeal as to the claims for increased initial ratings for migraine headaches and degenerative changes to his right shoulder in an April 2012 signed statement and, hence, there remain no allegations of errors of fact or law for appellate consideration as to these matters. Accordingly, the Board does not have jurisdiction to review the appeal and they are dismissed. ORDER The appeal as to the matter of an initial rating in excess of 30 percent for migraine headaches is dismissed. The appeal as to the matter of an initial rating in excess of 10 percent for degenerative changes to the right shoulder is dismissed. REMAND Initially, the Board notes that a VA examination report considered by the RO in the May 2007 rating decision on appeal is not currently in the claims file. The RO referenced review of VA general medical and spine and joint examination reports, dated on December 2 and 23, 2006, respectively. The December 23, 2006 VA examination report is in the claims file but the December 2, 2006 general medical examination report is not nor is it in the Veteran's Virtual VA electronic file. The examination report must be associated with the Veteran's claims file prior to appellate consideration of his claims on appeal. The Veteran seeks service connection for hyperactive parasympathetic syndrome. He testified that he experienced two episodes of the disorder in service, in 1983 and in 1985. See Board hearing transcript at page 20. During the first episode, in 1983, he stated that he was hospitalized for what was thought to be a heart attack. He was treated at Womack Army Community Hospital at Fort Bragg, North Carolina (Womack) and then sent to Walter Reed Army Medical Center (WRAMC) where he was found to have an unexplained syncopal episode with a clean bill of health. The Veteran further testified that, in 1985, he experienced a second episode while working during a volcano eruption in Columbia when he hit his shin, causing extreme pain. He was comatose again and treated with adrenaline to stimulate his heart and revive him. A temporary pacemaker was installed and he was sent to WRAMC again for evaluation. There doctors reportedly advised him that, rather than faint, his body over-reacted in stressful or painful circumstances, and closed down. A permanent pacemaker was offered but he opted to modify his personal and occupational activities. The Veteran stated that was particularly aware of his disorder with episodes of severe pain. Id. at 23. He also had high blood pressure. Id. Service records show that, in January 1982 and November 1985, the Veteran was treated for unexplained syncopal events and then transferred to Walter Reed Army Medical Center for evaluation. January 1982 records of treatment at Womack reflect that the Veteran was seen for complaint of syncopal episode while on a march. He was disoriented, unable to stand, and had no pulse after being loaded into an ambulance. He was treated at a private hospital, was alert and responsive, and then transferred to Womack. At discharge after one week, he was advised to modify his exercise program until the cause of his syncopal episodes was found. The discharge diagnoses included possible subendocardial infarction, syncopal episode, and hyperventilation. He was transferred to WRAMC for evaluation. In November 1985, while working in Colombia, the Veteran was hospitalized in Panama for complaint of chest pain radiating to the left shoulder and arm with bradycardia at admission. His 1982 treatment at Womack was noted, and that that he was evaluated at WRAMC in the Department of Cardiology, from January 24 to February 3, 1982. Evaluation at that facility reportedly indicated above normal cardiac function. His syncope was unexplained but neurological evaluation was normal. While hospitalized in Panama, a temporary pacemaker was placed and the Veteran was again transferred to WRAMC with consideration of placing a permanent pacemaker. The discharge diagnoses were coronary spasm with marked bradycardia, with impending asystole, and a history of cardio respiratory arrest in January 1982 (age 24). A December 1991 5 year-periodic service examination report does not discuss a cardiovascular or neurologic abnormality. Complete records of the Veteran's treatment at WRAMC are not in the claims file. For example, while a discharge summary from his 1982 hospitalization is of record, there are no reports dated between January 24, 1982, and February 3, 1982. There are also no reports from 1983. Further, while hospitalization reports from November 1985 are in the file, these are not from WRAMC, as the pre-date his admission to that facility on November 21. Therefore, efforts must be made to obtain these pertinent records prior to consideration of his claim. Additionally, according to records submitted by the Veteran, he had active and inactive duty in the United States Army Reserve from May 1992 to March 2002. Service treatment records dated from 1992 and from 1999 to 2006 are in the file, but records dated from 1993 to 1999 are not, raising the question as to whether his military records are complete. The Veteran should be requested to identify the Reserve unit with which he served from 1993 to 1999 and efforts should be made to obtain his service treatment records. Further, the Veteran testified that he is particularly aware of his claimed hyperactive parasympathetic syndrome disorder with severe pain. His service-connected migraine headaches, cervical and lumbar spine, bilateral knee, left wrist, and right shoulder disabilities are of such nature that could produce the type of severe pain that he related to his hyperactive parasympathetic syndrome. Thus, he appears to suggest that his claimed disorder is due to or aggravated by his service-connected disabilities. See Allen, supra. A June 1993 VA general medical examination report includes an impression of a history of syncopal episodes, most likely either vasovagal syncope or vagovagal syncopal episodes due to mediation of excess reflex reaction. The examiner found it noteworthy that the episodes occurred in the presence of infection processes, some of which at least involve the gastrointestinal tract. The examiner speculated that this may have been the origin of the problems. The Board finds that the Veteran should be afforded a VA examination to determine the nature and etiology of any hyperactive parasympathetic syndrome found to be present. 38 U.S.C.A. § 5103A(d) (West 2002 & Supp. 2012); 38 C.F.R. § 3.159 (2012); see also McClendon v. Nicholson, 20 Vet. App. 79, 83-86 (2006). The Veteran also seeks increased ratings for his service-connected lumbar spine, bilateral knee, and left wrist disabilities. He was last examined by VA in April 2012. Disabilities evaluated on the basis of limitation of motion require VA to apply the provisions of 38 C.F.R. §§ 4.40, 4.45 (2012), pertaining to functional impairment. The United States Court of Appeals for Veterans Claims (Court) has instructed that in applying these regulations VA should obtain examinations in which the examiner determines whether the disability is manifested by weakened movement, excess fatigability, incoordination, pain, or flare-ups. Such inquiry is not to be limited to muscles or nerves. These determinations are, if feasible, to be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, flare-ups, or pain. The examiner should also determine the point, if any, at which such factors cause functional impairment. Mitchell v. Shinseki, 25 Vet. App. 32, 43-4 (2011); DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997); 38 C.F.R. § 4.59 (2012). The Veteran testified that his lumbar spine disability limited his activities and required that he use lidocaine patches for pain. See Board hearing transcript at page 3. He had difficulty with any kind of activity, including normal household chores, tying his shoelaces, sitting for extended periods, standing, and walking. Id. at 4. The Veteran also testified that his left knee buckled, his knees occasionally locked, and he was unable to squat. See Board hearing transcript at page 11. Regarding his left wrist, the Veteran testified that he had unfavorable ankylosis and wore a brace issued by VA. See Board hearing transcript at page 13. His forearm impacted his wrist and he underwent surgical shortening of the ulna. Id. at 16. The Veteran was unable to rotate his wrist and, since his ulna surgery, was told to avoid striking the ulna or risk damaging it. Id. at 18. The Veteran also testified that his lumbar spine, bilateral knee, and left wrist disabilities worsened since he was last examined by VA. As such, additional action is required. See Caffrey v. Brown, 6 Vet. App. 377, 381 (1994) (determining that the Board should have ordered a contemporaneous examination of the Veteran because a 23-month-old examination was too remote in time to adequately support the decision in an appeal for an increased rating); Allday v. Brown, 7 Vet. App. 517, 526 (1995) (where the record does not adequately reveal the current state of claimant's disability, fulfillment of the statutory duty to assist requires a contemporaneous medical examination, particularly if there is no additional medical evidence that adequately addresses the level of impairment of the disability since the last examination). Moreover, during the March 2013 Board hearing, the Veteran's attorney argued that the left wrist disability should be separately rated to account for wrist and forearm symtoms. The Veteran's left wrist disability is currently assigned a 10 percent rating under 38 C.F.R. § 4.71a, Diagnostic Code 5229-5015 (2012), for limitation of motion of the index or long finger. This is the maximum allowable rating under these rating criteria. His attorney suggested that Diagnostic Code 5211, that evaluates impairment of the ulna, and Diagnostic Code 5214 that addresses ankylosis of the wrist, provided more appropriate and higher rating criteria. Under Diagnostic Code 5211, a 10 percent evaluation is warranted for malunion of the ulna with bad alignment. 38 C.F.R. § 4.71a, Diagnostic Code 5211 (2012). A 20 percent evaluation requires nonunion of the ulna of the major or minor upper extremity in the lower half. Id. A 20 percent evaluation for the minor arm and a 30 percent evaluation for the major arm requires nonunion in the upper half of the minor extremity with false movement and without loss of bone substance or deformity, and a 30 percent evaluation for the minor arm and a 40 percent for the major arm requires loss of bone substance (1 inch (2.5 centimeters) or more) and marked deformity. Id. Under Diagnostic Code 5214, a 20 percent disability evaluation is warranted when there is favorable ankylosis in 20 to 30 degrees dorsiflexion in the minor wrist. 38 U.S.C.A. § 4.71a, Diagnostic Code 5214 (2012). A higher 30 percent disability evaluation is contemplated for ankylosis of the minor wrist in any other position, except favorable. Id. A 40 percent rating is assigned for ankylosis of the minor wrist when ankylosis is unfavorable, in any degree of palmar flexion, or with ulnar or radial deviation. Id. Under Diagnostic Code 5215, a maximum 10 percent rating is assigned when there is limitation of motion of the wrist with dorsiflexion less than 15 degrees or with palmar flexion limited in line with the forearm. 38 U.S.C.A. § 4 .71a, Diagnostic Code 5215 (2012). The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided. 38 C.F.R. § 4.14 (2012). However, separate ratings may be assigned for distinct disabilities resulting from the same injury where the symptomatology for one condition is not duplicative of or overlapping with the symptomatology of the other condition. Esteban v. Brown, 6 Vet. App. 259, 262 (1994). Thus, consideration must be given to all symtoms associated with the Veteran's left wrist disability. Accordingly, the Board finds that the matter must be remanded because the current VA examination results do not describe the disabilities in detail sufficient to allow the Board to make a fully informed determination. Barr v. Nicholson, 21 Vet. App. 303 (2007) (citing Ardison v. Brown, 6 Vet. App. 405, 407 (1994)). Further, in Rice v. Shinseki, 22 Vet. App. at 447, the Court held that a TDIU claim is part of an increased rating claim when such claim is raised by the record. In this case, in a January 2013 written statement, his attorney argued that, given the Veteran's 80 percent combined disability rating, "VA failed to properly consider" the Veteran's claim for a TDIU, on a schedular and extra-schedular basis, under 38 C.F.R. §§ 4.16(a) (2012). The attorney contended that the Veteran had multiple disabilities of one or both upper or lower extremities such as to warrant one 60 percent disability or one 40 percent disability in combination. During his Board hearing, the Veteran stated that he was a student and in class three hours a day. See Board hearing transcript at page 5. Thus, the issue of a TDIU is raised by the record and the issue is properly before the Board. Having determined that the issue of TDIU is properly before the Board, it finds that further development is necessary prior to adjudicating the claim. The law provides that a 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 (West 2002); 38 C.F.R. §§ 3.340, 3.341, 4.16 (2012). 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 age or the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19 (2012). The record shows that the appellant is a student and evidently not working. He, through his attorney, alleges that his service-connected allergic rhinitis and migraine headaches, each evaluated as 30 percent disabling; degenerative joint disease of the lumbar spine, evaluated as 20 percent disabling; chondromalacia of the left knee, status post arthroscopic debridement, residuals of a ACL reconstruction of the right knee, osteoarthritis of the left hand and post-surgical residuals of the left ulna fracture, degenerative disc and joint disease of the cervical spine, and tinnitus, each evaluated as 10 percent disabling; and sinusitis and gastroesophageal reflux disease (GERD), both assigned noncompensable disability evaluations, prevent him from obtaining gainful employment. The Board notes that there is no opinion as to the Veteran's unemployability and the effect of his service-connected disabilities on his employability. The Board finds that the appellant should be afforded an appropriate VA examination to determine whether he is unable to secure or maintain substantially gainful employment as a result of his service-connected disabilities. Finally, the Veteran testified that he received his primary care medical treatment at the Washington VA hospital that issued a brace for his wrist. See Board hearing transcript at pages 13-14. However, records regarding the Veteran's treatment at the VA medical center (VAMC) in Washington, D.C., are not in the claims file. Thus, there appear to be some pertinent VA medical records that may affect the disposition of the instant claims that are not yet associated with the claim file. See Dunn v. West, 11 Vet. App. 462, 466-67 (1998); Bell v. Derwinski, 2 Vet. App. 611, 613 (1992) Accordingly, the case is REMANDED for the following action: 1. Contact the Veteran and request that he identify the United States Army Reserve unit with which he served from May 1992 to September 1999. 2. Then, contact the National Personnel Records Center, the Commander of the Veteran's United States Army Reserve unit (if he provides such information), the Adjutant General or Commander of the United States Army Reserve of Florida, and any other appropriate state and federal agency, and request the Veteran's active and inactive duty service treatment records from May 1992 to September 1999. 3. Contact the Walter Reed Army Medical Center in Washington, D.C., and request all records regarding the Veteran's treatment and evaluation at that facility from January 24, 1982 to February 3, 1982, and in November 1985. 4. Obtain all medical records regarding the Veteran's treatment at the VAMC in Washington, D.C., dated from October 2006 to the present, and from any additional VA and non-VA medical provider identified by him. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. Ordinarily at least two requests for the record will be required unless it is reasonably certain that further efforts would be futile. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C.A. § 5103A(b)(2) (West 2002 & Supp. 2012) and 38 C.F.R. § 3.159(e) (2012). 5. Obtain a complete copy of the report of the Veteran's December 2, 2006 VA General Medical examination performed at the Miami VAMC, and associate it with the claims file. 6. The RO/AMC should forward an appropriate form (VA From 21-8940) and request that the Veteran return the form providing a complete employment history from October 2006. The RO/AMC should request that the Veteran provide exact dates of employment, including month, day and year. 7. After the above development is accomplished, schedule the Veteran for appropriate VA examination(s), i.e., neurological, cardiovascular, performed by physicians with expertise (i.e., neurologist, cardiologist) to determine the current nature and etiology of any hyperactive parasympathetic syndrome found to be present. A complete history of the claimed disorder should be obtained from the Veteran. All indicated tests and studies should be accomplished and all clinical findings reported in detail. The claims file should be made available to the examiner prior to the examination. a. Does the Veteran have hyperactive parasympathetic syndrome or another syncopal disorder? b. If so, is it at least as likely as not that any hyperactive parasympathetic syndrome had its clinical onset or is otherwise related to the Veteran's active duty? c. The examiner(s) should indicate whether any diagnosed hyperactive parasympathetic syndrome disorder is as likely as not (50 percent probability or greater) related to the Veteran's active service or the result of service-connected low back, cervical spine, bilateral knee, left wrist, right shoulder, migraine headaches, and allergic rhinitis disabilities, including related pain. If not, is it at least as likely as not aggravated by service-connected low back, cervical spine, bilateral knee, left wrist, right shoulder, migraine headaches, and allergic rhinitis disabilities, including related pain? If aggravated, what permanent, measurable increase in current hyperactive parasympathetic syndrome pathology is attributable to the service-connected low back, cervical spine, bilateral knee, left wrist, right shoulder, migraine headaches, and allergic rhinitis disabilities, including related pain? d. The examination report(s) should include the complete rationale for all opinions expressed. 8. Schedule the Veteran for VA orthopedic and neurologic examination to determine the current severity and all manifestations of his service connected lumbar spine, right and left knee, and left wrist disabilities. All indicated tests and studies should be performed and all clinical findings reported in detail. a. The examiner should provide range of motion in degrees, to include the degree at which pain begins, for the lumbar spine, both knees, and left wrist. The examiner should also provide a specific opinion as to whether there is additional limitation of motion due to weakened movement, excess fatigability, incoordination, pain, or flare-ups. The examiner should express this opinion in terms of the degree of additional range-of- motion loss (in degrees) due to any weakened movement, excess fatigability, incoordination, flare-ups, or pain. In this regard, the examiner should estimate the extent of any additional functional limitation manifested during periods of flare-up. Such additional limitation should be expressed in degrees of motion lost during flare-ups. The Veteran's reported symptoms should be considered in making this determination. If the examiner rejects the Veteran's reports, he or she must provide a reason for doing so. b. The examiner should specifically address the following: i. Lumbar Spine: 1. Whether there are muscle spasms or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. 2. Whether there is any ankylosis, either favorable or unfavorable, of the Veteran's lumbar spine. 3. Whether the Veteran has intervertebral disc syndrome of the lumbar spine and, if so, identify the number of incapacitating episodes involving physician-prescribed bed rest, if any, within the last 12-month period. 4. The examiner should also identify any associated neurological deformities associated with the service-connected lumbar spine disorder, to include any radiculopathy or neuropathy of the upper and lower extremities, and any associated bladder or bowel impairment. 5. The severity of each neurological sign and symptom must be reported, if such exists, as mild, moderate, moderately severe, or severe in nature, and whether such represents symptomatology that more closely approximates incomplete or complete paralysis of the affected nerves. ii. Knees: 1. The examiner should report if there is ankylosis of either knee and, if so, the angle at which the knee is held. 2. The examiner should also report whether there is subluxation or instability of either knee and, if present, provide an opinion as to its severity. 3. The examiner should also report the nature and severity of any impairment of the tibia and fibula, including the severity of any associated knee disability, any malunion or nonunion of the tibia and fibula, and whether there is any loose motion requiring a brace. iii. Left Wrist: 1. The examiner should report whether there is ankylosis of the left wrist and, if so, the angle at which it is held. 2. The examiner should report if there is favorable ankylosis of the left wrist at 20 to 30 degrees of dorsiflexion. 3. The examiner should report if there is nonunion in the lower half of the Veteran's left ulna. 4. The examiner should identify the symptoms of the Veteran's left hand osteoarthritis and of the residuals of his left ulna fracture. The examiner should explain whether such symptoms are entirely overlapping or whether each has its own manifestations. c. The examiner is also asked to comment on the impact of the claimed increase in severity of the Veteran's lumbar spine, bilateral knee, and left wrist disabilities, if any, on the his ability to obtain and sustain substantially gainful employment, and activities of daily life. A complete rationale for any opinion expressed shall be provided. 9. Schedule the Veteran for appropriate VA examination(s) (neurologic, orthopedic, ear, nose, and throat, gastrointestinal) to determine the effect of these service-connected disabilities (migraine headaches and allergic rhinitis, each rated 30 percent disabling; degenerative changes of the right shoulder and tinnitus, each rated 10 percent disabling; and sinusitis and GERD, each rated noncompensable) on his employability (in so doing, the examiner's should consider the net effect of all service-connected disabilities on the Veteran's employability). The examiner(s) should offer an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran is unable to secure or maintain substantially gainful employment solely as a result of his service-connected disabilities (migraine headaches, allergic rhinitis, degenerative changes of the right shoulder, tinnitus, sinusitis, and GERD). The examination reports must include a complete rationale for all opinions and conclusions expressed. 10. Thereafter, readjudicate the Veteran's claims for increased initial ratings for his bilateral knee, lumbar spine, and left hand/wrist disabilities, and service connection for hyperactive parasympathetic syndrome, including as due to service-connected disabilities, and adjudicate his claim for a TDIU in light of any evidence added to the record. If any benefit sought on appeal remains denied, the appellant and his attorney should be provided a supplemental statement of the case (SSOC). An appropriate period of time should be allowed for response. No action is required of the Veteran until he is notified by the RO; however, the Veteran is advised that failure to report for any scheduled examination may result in the denial of his claim. 38 C.F.R. § 3.655 (2012). 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. 2012). ______________________________________________ ERIC S. LEBOFF Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs