Citation Nr: 1321690 Decision Date: 07/08/13 Archive Date: 07/18/13 DOCKET NO. 09-27 952 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to an initial rating in excess of 30 percent for adjustment disorder. 2. Entitlement to an initial rating in excess of 10 percent for sinusitis. 3. Entitlement to an initial, compensable evaluation hypertension. 4. Entitlement to an initial rating in excess of 30 percent for myotonic dystrophy type II. 5. Entitlement to a total disability rating for compensation purposes based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran, and her mother and father ATTORNEY FOR THE BOARD C. Hancock, Counsel INTRODUCTION The Veteran served on active duty from January 2004 to February 2008. These matters come to the Board of Veterans' Appeals (Board) on appeal from a rating decision dated in April 2008 by the Department of Veterans Affairs (VA) Regional Office (RO) in San Diego, California. The claims are now under the jurisdiction of the RO in Roanoke, Virginia. In the April 2008 rating decision, the RO granted service connection and assigned a single 30 percent rating for myotonic dystrophy type II with mild adjustment disorder, effective from February 15, 2008. In a July 2012 rating decision, the RO assigned a separate 30 percent rating for adjustment disorder, effective from September 11, 2008. The Veteran provided testimony before the undersigned Veterans Law Judge at a hearing conducted at the RO in March 2013. A hearing transcript (transcript) has been associated with the Veteran's claims folder. The issues of entitlement to an increased rating for migraine headaches and TDIU have been raised by the record, but have not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and is it referred to the AOJ for appropriate action. The issue of entitlement to an increased rating for myotonic dystrophy type II, is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. For the entire initial rating period, the Veteran's adjustment disorder has been manifested by complaints of depressed mood, anxiety, and trouble sleeping; the disorder is not manifested by occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; difficulty in establishing and maintaining effective work and social relationships. 2. For the entire initial rating period, the Veteran's sinusitis has been manifested by complaints of sinus infections, sneezing, headaches, congestion, purulent discharge, and four non-incapacitating episodes per year; the Veteran's sinusitis has not been evidenced by three or more incapacitating episodes of sinusitis requiring prolonged antibiotic treatment; or more than six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge and crusting. 3. For the entire initial rating period, the Veteran's hypertension has required continuous medication for control; however, it has not been manifested by diastolic pressure predominantly 100 or more or systolic pressure predominantly 160 or more. CONCLUSIONS OF LAW 1. For the entire initial rating period, the criteria for the assignment of an initial rating in excess of 30 percent for the service-connected adjustment disorder have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.130, Diagnostic Code 9440 (2012). 2. For the entire initial rating period, the criteria for the assignment of an initial rating in excess of 10 percent for the service-connected sinusitis have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.97, Diagnostic Code 6513 (2012). 3. For the entire initial rating period, the criteria for the assignment of an initial compensable rating for the service-connected hypertension have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.104, Diagnostic Code 7101 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS 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). This appeal arises from the Veteran's disagreement with the initial evaluations following the grants of service connection. Once service connection is granted the claim is substantiated, additional notice is not required, and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). No additional discussion of the duty to notify is therefore required. VA also has a duty to assist the Veteran in the development of the claim, which is not abrogated by the granting of service connection. The Veteran's service treatment records, Tricare treatment records, and VA medical treatment records have been obtained. 38 U.S.C.A. § 5103A, 38 C.F.R. § 3.159. Numerous adequate VA examinations were conducted to assess the severity of the Veteran's disabilities, including most recently in February 2012. The VA examination reports are adequate for rating purposes. 38 C.F.R. § 3.159(c) (4); Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). The duties to notify and assist have been met. Laws and Regulations The Veteran seeks increased ratings for her service-connected adjustment disorder, sinusitis, and hypertension. Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. Ratings are based on the average impairment of earning capacity. See 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. During an appeal of a disability rating, either from an initial rating assigned on granting of service connection or on appeal of a subsequent denial of an increased rating, it may be found that there are varying and distinct levels of disability impairment severity during an appeal. So, staged ratings (different disability ratings during various time periods) are appropriate when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Fenderson v. West, 12 Vet. App. 119 (1999). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Veteran's adjustment disorder is currently evaluated as 30 percent disabling, under 38 C.F.R. § 4.130, Diagnostic Code 9440. Although the Veteran is of the belief that her service-connected psychiatric disorder is more along the lines of an anxiety disorder (see March 2013 hearing transcript), both adjustment disorders and anxiety disorders are rated under the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130. Under Diagnostic Code 9440, a 30 percent rating is warranted for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood; anxiety; suspiciousness; panic attacks (weekly or less often); chronic sleep impairment; and/or mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to compete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating contemplates occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. Id. A 100 percent rating is warranted when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. The above set of symptoms is not an exclusive or exhaustive list, as evidenced by use of the phrase "such symptoms as," followed by a list of examples. So, rather, it serves as merely an example of the symptoms that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In determining whether the Veteran meets the criteria for a higher rating, the Board must consider whether she has deficiencies in most of the following areas: work, school, family relations, judgment, thinking, and mood. Bowling v. Principi, 15 Vet. App. 1, 11 (2001). In Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013), the Federal Circuit stated that "a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration." It was further noted that "§ 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas." One factor for consideration is the Global Assessment of Functioning (GAF) score, which is a scaled rating reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996), citing Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV). The higher the score, the higher the overall functioning of the individual is. Concerning the claim seeking an initial rating in excess of 10 percent for the service-connected sinusitis, under Diagnostic Code 6513, a 10 percent evaluation is for application when sinusitis results in one or two incapacitating episodes per year requiring prolonged (lasting four to six weeks) antibiotic treatment, or; three to six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. See 38 C.F.R. § 4.97. A 30 percent evaluation is applicable when there are three or more incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or; more than six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. Id. A 50 percent rating is for application following radical surgery with chronic osteomyelitis, or near constant sinusitis characterized by headaches, pain and tenderness of affected sinus, and purulent discharge or crusting after repeated surgeries. A Note accompanying the rating criteria defines an incapacitating episode as one that requires bed rest and treatment by a physician. Id. Regarding the Veteran's claim seeking an initial compensable rating for her service-connected hypertension, under Diagnostic Code 7101 (see 38 C.F.R. § 4.104), in every instance in which the Ratings Schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31 (2012). Under Diagnostic Code 7101, a 10 percent disability rating requires diastolic pressure predominantly 100 or more, or; systolic pressure predominantly 160 or more, or; that an individual with a history of diastolic pressure predominantly 100 or more requires continuous medication for control. A 20 percent disability rating requires diastolic pressure predominantly 110 or more, or; systolic pressure predominantly 200 or more. A 40 percent disability rating requires diastolic pressure predominantly 120 or more. A 60 percent disability rating require diastolic pressure predominantly 130 or more. Factual Background Shortly before her service separation in February 2008, the Veteran submitted a claim seeking service connection for, among other disorders, anxiety disorder, sinusitis, and hypertension. See VA Form 21-526, received in January 2008. A March 2008 VA X-ray report shows that four views of the sinuses demonstrated clear and well aerated sinuses. Clear sinuses was diagnosed. The report of a March 2008 VA mental disorders examination shows that the Veteran reported that her myotonic dystrophy type II had caused her anxiety problems with insomnia. Anxiety disorder, not otherwise specified, was diagnosed in August 2007, during the Veteran's period of active service. This condition however, was noted to be in full remission without the benefit of medication. Past medication use was reported for her anxiety symptoms. The Veteran reported no current complaints. She denied any previous psychiatric-based hospitalizations. Examination was essentially normal. The examiner commented that there were no effects on employment or social life due to her symptoms or diagnosis. Her behavior was described as totally normal. The diagnosis was history of mild adjustment disorder due to myotonic dystrophy, currently in full remission. A GAF score of 70 was provided. Review of a VA general medical examination report dated in March 2008 notes that the Veteran provided a history of sinusitis, worse in the spring and fall. She also provided a history of CT (computed tomography) scan findings of a sinus cyst. To this, a September 2006 in-service CT report shows the presence of a right maxillary sinus mucous retention cyst. Use of antibiotics (three to four times a year) was also reported. Exacerbations of her sinuses were noted to cause headaches. The Veteran reported taking allergy shots and Zyrtec for one year; this provided moderate relief. While a diagnosis of essential hypertension was reported, the examiner observed that normal blood pressure readings were included throughout the Veteran's records. The Veteran did report periods of elevated blood pressure findings when extremely stressed out, and after periods of episodic [service-connected] tachycardias. The examiner commented that, while the Veteran had a diagnosis of hypertension, she had not been on anti-hypertensive medications and did not have persistent hypertension. Examination of the Veteran showed blood pressure readings of 122/84, 120/72, and 122/76. Concerning her sinuses, pressure over the sinuses caused no undue discomfort. The Veteran demonstrated slight clear nasal discharge with a little bit of a sniffle from time to time in the examination room, but she had good airflow through both nostrils and ever-so-slight nasal hyperemia in the nostrils. The diagnoses included essential hypertension. The Veteran was noted to be on no medications, and three blood pressure readings made in the course of the examination were all normal. Allergic sinusitis/rhinitis with episodic need for antibiotics three to four times a year was also diagnosed. Headaches were noted to accompany these sinus infections. A July 2008 Tricare treatment record shows that the Veteran's blood pressure was 112/70. The Veteran reported taking over the counter medication for trouble sleeping. She complained of increased anxiety. A past use of Paxil and Ambian in the military was noted. Insomnia and anxiety were diagnosed. An August 2008 Tricare treatment record shows that the Veteran's blood pressure was 120/90. The Veteran was seen for complaints of constant sinus pressure and headache for four days. She added that her migraine medication was not working. Acute maxillary sinusitis was diagnosed. The examiner commented that the Veteran's blood pressure was elevated, and that the Veteran had a sinus infection. A September 2008 VA primary care note found in Virtual VA shows that the Veteran was prescribed Paxil for her anxiety. A September 11, 2008 VA social work consult, also in Virtual VA, notes that the Veteran reported recently breaking up with her boyfriend and of being diagnosed with muscular dystrophy. Mental status examination showed her appearance to be appropriately groomed and tense. Her attitude was frank and direct. Speech was normal, mood was depressed and irritable. Affect was depressed, and she denied both suicidal and homicidal thoughts. Judgment and insight were fair. She was oriented to all spheres. Concentration was also described as fair. Depression, dysthmic disorder was diagnosed. An October 2008 Tricare treatment record shows a blood pressure measurement of 122/76. The Veteran at this time complained of increased sinus pressure, with sneezing and congestion, for a duration of two days. The Veteran was provided steroid nasal spray for congestion. A prescription of Xyral was also provided, to assist with runny nose and post nasal drainage. A December 2008 VA outpatient treatment record shows a blood pressure reading of 133/82. Hypertension was diagnosed. The Veteran was shown to be started on Metoprolol twice daily for heart rate and blood pressure. An August 2011 cardiology history and physical report includes multiple blood pressure findings, all shown to have been taken within 20 minutes of each other. These included the following: 114/89, 131/80, 136/84, 125/91, 120/83, 112/76, 105/70, 123/63, 98/65, 129/82, 103/76, and 127/62. The report of a November 2011 psychiatric examination for VA shows that mild adjustment disorder was diagnosed. A GAF score of 71 was provided. The examiner noted the presence of the following symptoms: anxiety and chronic sleep impairment. The Veteran gave a history of having insomnia, mild anxiety, irritability, and feeling weak. The symptoms, noted to be mild, were also reported to be constant. The Veteran reported currently taking Zoloft, and denied any psychotherapy or hospitalizations within the past year. The Veteran reported having worked for the past 2.5 years as an electrical technician. The examiner commented that the Veteran was able to establish and maintain effective work/school and social relationships. The examiner characterized the psychiatric symptoms as being mild or transient but causing occupational and social impairment with decrease in work efficiency and occupational tasks only during periods of significant stress. A November 2011 VA fee-basis sinus X-ray report showed findings reflective of left maxillary inflammation; it was noted to be unknown if this condition was chronic or acute. The report of a February 2012 sinus examination for VA reveals that the Veteran reported sinus problems occurring three times per year, with each episode lasting for four weeks. During these episodes, the Veteran denied being incapacitated. She added that she had four non-incapacitating episodes per year. Headaches were reported to accompany all of her sinus episodes. The Veteran noted that she required antibiotics to treat her sinus problems, but such medication usage did not last four to six weeks. The Veteran also reported difficulty breathing through her nose, with purulent discharge from her nose and voice hoarseness. She denied both pain and crusting. As concerning her service-connected hypertension the Veteran provided a history of elevated blood pressure, treated with good results with medication. On examination, the Veteran's blood pressure was measured as being 134/82, 130/78, and 132/80. The Veteran was noted to be taking Metoprolol. Examination of the nose showed no nasal obstruction, no deviated septum, and no partial loss of nose, no nasal polyps, no scar and no disfigurement. Sinusitis was present at the maxillary with tenderness. Purulent discharge from the nose was also present. The diagnoses included essential arterial hypertension and sinusitis. The report of a March 2012 CT sinus examination report, provided by the Veteran at her March 2013 hearing, shows no acute sinus disease. A retention cyst in the inferior left maxillary sinus was present. The report noted that a retention cyst was a benign finding. At the outset of the March 2013 hearing, the Veteran waived initial RO consideration of evidence submitted. This evidence has been associated with her claims folder. Concerning her service-connected adjustment disorder, the Veteran testified that she was no longer being treated for or taking medication this disorder. She described her symptoms as being similar to anxiety. She did report previously having panic attacks. It was also reported that she had trouble sleeping every night. The Veteran was not sure if this was due to her psychiatric-based disorder or to pain stemming from her myotonic dystrophy. She added she had difficulty making friends, but was able to maintain relationships with her relatives and boyfriend. Concerning the service-connected sinusitis, the Veteran submitted a March 2012 CT scan report which she asserted showed the presence of a retention cyst. She denied having sinus-related surgery. The Veteran also reported suffering from sinus infections three or four times a year, causing her to need to take antibiotics. Headaches were also noted to accompany these sinus infections. The Board parenthetically observes that the Veteran is service-connected for migraine headaches. The Veteran did note that her sinus symptoms could cause her to have a migraine headache. Her antibiotics were noted to be provided her from Tricare, since the facility was closer than the nearest VA facility. The Veteran testified her last sinus infection had occurred the previously year. As concerning her service-connected hypertension, the Veteran testified that she was taking Metoprolol. This medication was noted to treat both her heart disorder and her hypertension. The hypertension was essentially noted to be successfully managed with medication. Analysis Adjustment Disorder After considering all of the evidence of record, including particularly a September 11, 2008, VA social work outpatient treatment note, the report of a November 2011 VA fee-basis examination, as well as the Veteran's recent March 2013 hearing testimony, the Board finds that the Veteran's psychiatric disorder does not warrant a rating in excess of 30 percent at any time from September 11, 2008. In this regard, for the applicable period of time, the medical evidence fails to demonstrate that the criteria set out in 38 C.F.R. § 4.130 (Diagnostic Code 9440), and necessary for the assignment of a 50 percent rating, have been met. Of particular note, review of the psychiatric-based medical evidence fails to demonstrate that the Veteran suffered from symptoms such as circumstantial, circumlocutory, or stereotyped speech, panic attacks (occurring more than once a week), difficulty in understanding complex commands, impairment of long-term memory, impaired judgment, or impaired abstract thinking. Further, a GAF score of 71 was supplied in November 2011. A GAF score between 71 and 80 indicates that if symptoms are present, they are transient and expectable reactions to psychosocial stressors; no more than slight impairment in social, occupational, or school functioning. See DSM-IV at 46-47. The November 2011 examiner specifically characterized the Veteran's psychiatric symptoms as being mild or transient but causing occupational and social impairment with decrease in work efficiency and occupational tasks only during periods of significant stress. The Board also finds noteworthy that the Veteran testified in March 2013 that she was no longer using medication to treat her psychiatric disorder, and that she was not being treated for this disorder. "§ 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas." See Vazquez-Claudio, supra. The areas referenced by a 50 percent rating under § 4.130 are occupational and social impairment with reduced reliability and productivity and difficulty in establishing and maintaining effective work and social relationships. The evidence here does not show that the symptoms of the Veteran's service-connected psychiatric disability are of sufficient severity and frequency to approximate that level of impairment. Therefore, the Board concludes that an increased rating is not in order at any time during the appeal period. The benefit sought on appeal is denied. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the appellant's claim, the doctrine is not for application. Gilbert. Sinusitis After complete review of the evidence of record, the Board concludes that the criteria for a rating in excess of 10 percent for sinusitis are not met at any time during the appellate period. The Board acknowledges the Veteran's complaints of nasal discharge, sneezing, congestion, and headaches, and notes her occasional need for antibiotics. Observing that the Veteran complained of headaches with sinus-related exacerbations, the Board notes she is service-connected for migraine headaches. The relevant evidence received during the current appeal reflects relatively minimal pathological findings. For instance, it has not been documented that she has required bed rest or more than occasional treatment by a physician. In fact, in February 2012 the Veteran denied having incapacitating episodes. At that same time she reported having four non-incapacitating episodes a year. Without evidence of three or more incapacitating episodes per year of sinusitis requiring prolonged antibiotic treatment, or more than six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting, a 30 percent rating is not warranted. 38 C.F.R. § 4.97, Diagnostic Code 6513, Note after Diagnostic Code 6514. The benefit sought on appeal is denied. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the appellant's claim, the doctrine is not for application. Gilbert. Hypertension Following its complete review of the evidence of record, the Board concludes that the criteria for a rating in excess of 10 percent for sinusitis are not met at any time during the appellate period. Review of the medical evidence of record reveals that the Veteran has been diagnosed with hypertension since during her active duty. However, the records fail to demonstrate that her diastolic pressure has been predominantly 100 or more, her systolic pressure has been predominantly 160 or more, or that she had required continuous medication for a history of diastolic pressure predominantly 100 or more. Numerous blood pressure readings on file, and dated during the appeal period, as discussed above, support these conclusions. As such, based on a review of the evidence of record, the Board concludes that a compensable evaluation for hypertension under Diagnostic Code 7101 is not warranted. Rather, the medical evidence demonstrates that her blood pressure readings throughout the period on appeal more closely approximate the criteria for a noncompensable evaluation. Specifically, the Board notes that although the Veteran was prescribed medication to control her hypertension, there is no indication that she ever had predominant diastolic readings of 100 or more, or predominant systolic readings of 160 or more. For these reasons, the Board concludes that the Veteran's hypertension does not more nearly approximate the criteria for a compensable disability rating. The benefit sought on appeal is denied. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the appellant's claim, the doctrine is not for application. Gilbert Extraschedular Consideration The discussion above reflects that the rating criteria reasonably describes and contemplates the severity and symptomatology of the Veteran's service-connected disabilities. The Veteran's psychiatric disability is manifested by impairment in social and occupational functioning; the rating criteria specifically contemplate these impairments. Her sinusitis is manifested by nasal discharge, sneezing and the occasional need for antibiotics; all specifically contemplated by the rating criteria. As discussed above, there is a higher rating available under the applicable diagnostic code, but the Veteran's hypertension is not productive of the manifestations that would warrant the higher rating. Thus, 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. Thun v. Peake, 22 Vet. App. 111 (2008). ORDER Entitlement to an initial evaluation in excess of 30 percent for adjustment disorder is denied. Entitlement to an initial evaluation in excess of 10 percent for sinusitis is denied. Entitlement to an initial compensable evaluation for hypertension is denied. REMAND Additional development of the evidence is necessary in connection with the claim for increased rating for myotonic dystrophy type II. The Board first observes that myotonic dystrophy type 2 is a rare genetic disease. See http://rarediseases.info.nih.gov/gard/9728/myotonic-dystrophy-type-2/resources/1. It is one of the two types of myotonic dystrophy, is an inherited type of muscular dystrophy that affects the muscles and other body systems (e.g., heart, eyes, pancreas). The condition is characterized by prolonged muscle tensing (myotonia) as well as muscle weakness, pain, and stiffness. Signs and symptoms of myotonic dystrophy usually develop during the twenties or thirties. Muscles in the neck, fingers, elbows, and hips are typically affected by this condition. Facial and ankle muscles may also be affected but are less commonly involved. The severity of myotonic dystrophy type 2 varies widely among affected individuals, even among family members. The condition is inherited in an autosomal dominant pattern and is caused by mutations in the CNBP gene. Treatment is based on the individual's specific signs and symptoms. Id. The Veteran testified in March 2013 that her symptoms included daily constant pain, mostly in her legs. She mentioned that most of her treatment was through VA, but some had been through private providers (Tricare), most recently in January 2013. The Veteran's mother testified that the Veteran's myotonic dystrophy causes her to stumble when she was tired and the Veteran reported that she had fallen down stairs. The Veteran also testified that she had difficulty gripping and lifting things and that sometimes her hands and feet become completely numb. Medical evidence on file concerning the Veteran's myotonic dystrophy includes the report of a March 2008 VA neurological disorders examination and a July 2012 examination for VA. The report noted that the location of the condition was "all through the body." The RO has rated the Veteran's myotonic dystrophy type II under Diagnostic Code 8023 (see 38 C.F.R. § 4.124a), pertaining to progressive muscular atrophy, which provides a minimum rating of 30 percent. Governing regulation provides that disability from the following diseases (including progressive muscular atrophy) and their residuals may be rated from 10 percent to 100 percent in proportion to the impairment of motor, sensory, or mental function. 38 C.F.R. § 4.124a. Consideration should be afforded to psychotic manifestations, complete or partial loss of use of one or more extremities, speech disturbances, impairment of vision, disturbances of gait, tremors, and visceral manifestations, referring to the appropriate bodily system of the schedule. Id. A note under Diagnostic Code 8025 further provides that ratings in excess of the prescribed minimum rating may be assigned for ascertainable residuals, and the diagnostic codes utilized as bases of evaluation should be cited in addition to the codes identifying the diagnoses. In other words, a higher rating may be assigned based upon the combined evaluations of the residuals of the Veteran's myotonic dystrophy type II. The Board is of the opinion that the medical evidence currently available to it is insufficient to adequately rate the Veteran's myotonic dystrophy type II. It is not clear what "ascertainable residuals" are currently manifested pertaining to this instant service-connected disability. The Veteran is separately service connected for several disabilities, including vasovagal syncope, palpitations with sinus tachycardia and migraine headaches. Manifestations of those disabilities should not be considered in determining the severity of the service-connected myotonic dystrophy. The Board finds that, on remand, the Veteran should be scheduled for an updated VA examination which addresses the current nature and severity and to identify all ascertainable residuals of the Veteran's myotonic dystrophy type II. The Veteran testified at the recent hearing that she last worked in November 2012 and that she needed to leave that job because it placed her at a desk for too long a period of time and that was painful. The issue of entitlement to a TDIU has been raised during the pendency of the appeal, but it has not been developed or adjudicated by the RO or AMC to date. Rice v. Shinseki, 22 Vet. App. 447 (2009); Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). The July 2012 examination for VA did not include the examiner's assessment of functional impact of the Veteran's myotonic dystrophy. Accordingly, the case is REMANDED for the following action: 1. The RO/AMC should schedule the Veteran for a VA neurological examination to determine the current level of severity of her service-connected myotonic dystrophy type II. The claims file must be provided to and reviewed by the examiner. All necessary tests should be performed, as determined by the examiner. The examiner should be asked to identify the nature and severity of all ascertainable residuals of the Veteran's myotonic dystrophy type II, including any impairment of motor, sensory, or mental function. The examiner is specifically requested to fully describe the functional effects caused by the Veteran's myotonic dystrophy type II. The examiner should provide a rationale for any opinion provided. 2. The Veteran is hereby notified that it is her responsibility to report for any and all scheduled examinations and to cooperate in the development of the claim. The consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2012). In the event that the Veteran does not report for a scheduled examination, documentation should be obtained which shows that notice scheduling the examination was sent to the last known address. It should also be indicated whether any notice that was sent was returned as undeliverable. 3. After completion of the foregoing, schedule the Veteran for an appropriate VA medical examination to determine whether the her service-connected disabilities render her unemployable. The examiner is requested to furnish an opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's service-connected disabilities (myotonic dystrophy; adjustment disorder; vasovagal syncope; sinusitis; palpitations with sinus tachycardia; migraine headaches; lumbosacral strain/sprain; allergic rhinitis; essential hypertension; and rosacea) either singly or taken together, render her unable to secure or follow a substantially gainful occupation. Detailed rationale is requested for the opinion provided. 4. Following completion of the foregoing, the RO/AMC must review the claim folder and ensure that all of the foregoing development actions have been conducted and completed in full. If any development is incomplete, appropriate corrective action is to be taken. Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141 (1999). 5. Thereafter, and following any other indicated development, the RO/AMC should adjudicate the claim for TDIU and increased rating for myotonic dystrophy. If the appeal is denied, the Veteran and her representative should be provided a supplemental statement of the case (SSOC). The appellant has the right to submit additional evidence and argument on the matter 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 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. 2012). ______________________________________________ M. E. LARKIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs