Citation Nr: 1325393 Decision Date: 08/12/13 Archive Date: 08/16/13 DOCKET NO. 09-18 534 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Huntington, West Virginia THE ISSUES 1. Entitlement to an evaluation in excess of 10 percent for residuals of a right wrist fracture with possible early osteoarthritis. 2. What evaluation is warranted for posttraumatic stress disorder (PTSD) from August 5, 2008 to December 18, 2011? 3. What evaluation is warranted for PTSD from December 19, 2011? 4. What evaluation is warranted for a right hand disability manifested by decreased grip strength from November 28, 2007? REPRESENTATION Appellant represented by: David L. Huffman, Attorney at Law WITNESSES AT HEARING ON APPEAL Appellant and spouse ATTORNEY FOR THE BOARD P. Olson, Counsel INTRODUCTION The Veteran had active military service from March 1990 to September 1993. This matter comes before the Board of Veterans' Appeals (Board or BVA) on appeal from rating decisions in July 2008, January 2009, and January 2010 of the Department of Veterans Affairs (VA) Regional Office (RO) in Huntington, West Virginia. In January 2013, the Veteran testified at a videoconference hearing. A transcript of that hearing is a part of record via Virtual VA. The issue of entitlement to service connection and separate disability compensation for right ulnar nerve paralysis has been raised by the record, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). In addition, the record raises the issues of entitlement to service connection for Lyme disease and a disability manifested by symptoms of an undiagnosed illness the review. These issues, however, are not currently developed or certified for appellate review. Accordingly, they are referred to the RO for appropriate consideration. The issue of what evaluation is warranted for PTSD from December 19, 2011 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. During the appeal period, the Veteran's residuals of a right wrist fracture have not been manifested by ankylosis. 2. From August 5, 2008 to December 18, 2011, the Veteran's PTSD was not productive of occupational and social impairment with deficiencies in most areas. 3. Since November 28, 2007, the Veteran's right hand disability with decreased grip strength has been productive of no more than moderate incomplete paralysis. CONCLUSIONS OF LAW 1. For the entire appeal period, the criteria for an evaluation in excess of 10 percent for residuals of a right wrist fracture with osteoarthritis have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.1, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5214, 5215 (2012). 2. From August 5, 2008 to December 18, 2011, the criteria for an evaluation in excess of 50 percent for PTSD were not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.130, Diagnostic Code 9411 (2012). 3. Since November 28, 2007, the criteria for an evaluation in excess of 30 percent for right hand disability manifested by decreased grip strength have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.124a, Diagnostic Code 8514 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist With respect to the issue of entitlement to an evaluation in excess of 10 percent for residuals of a right wrist fracture with osteoarthritis, the requirements of 38 U.S.C.A. §§ 5103 and 5103A have been met. There is no issue as to providing an appropriate application form or completeness of the application. VA notified the Veteran in December 2007 and April 2009 of the information and evidence needed to substantiate and complete a claim, to include notice of what part of that evidence is to be provided by the claimant, what part VA will attempt to obtain, and how disability ratings and effective dates are determined. The case was readjudicated in June 2011. VA fulfilled its duty to assist the Veteran in obtaining identified and available evidence needed to substantiate a claim, and as warranted by law, affording VA examinations. There is no evidence that additional records have yet to be requested, or that additional examinations are in order. With respect to the remaining issues on appeal, as service connection, initial ratings, and effective dates have been assigned, the notice requirements of 38 U.S.C.A. § 5103(a) have been met. Hartman v. Nicholson, 19 Vet. App. 473, 490 (2006). VA has fulfilled its duty to assist the Veteran in obtaining identified and available evidence needed to substantiate a claim, and as warranted by law, affording VA examinations. He was provided the opportunity to present pertinent evidence and testimony. In sum, there is no evidence of any VA error in notifying or assisting him that reasonably affects the fairness of this adjudication. 38 C.F.R. § 3.159(c). Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Veteran is appealing the original assignment of disability evaluations following an award of service connection for PTSD and decreased right hand grip strength. As such, it is not the present level of disability which is of primary importance, but rather the entire period is to be considered to ensure that consideration is given to the possibility of staged ratings; that is, separate ratings for separate periods of time based on the facts found. Fenderson v. West, 12 Vet. App. 119 (1999). With respect to the issue of entitlement to a higher evaluation for residuals of a right wrist fracture with osteoarthritis, the Veteran is requesting a higher rating for an already established service-connected disability, the present disability level is the primary concern and past medical reports do not take precedence over current findings. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, "staged" ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Residuals of Right Wrist Fracture The Veteran seeks an evaluation in excess of 10 percent for residuals of a right wrist fracture with osteoarthritis. The 10 percent rating for the right wrist was assigned by analogy to 38 C.F.R. § 4.71a, Diagnostic Code 5010. When a Veteran is diagnosed with an unlisted condition, it must be rated under an analogous diagnostic code. 38 C.F.R. §§ 4.20. Under this regulation the disorder is rated by analogy under a diagnostic code for a closely related disease or disorder that affects the same anatomical functions and has closely analogous symptomatology. Diagnostic Code 5010 provides that arthritis due to trauma, substantiated by X-ray findings, is rated as degenerative arthritis. 38 C.F.R. § 4.71a, Diagnostic Code 5010. In turn, degenerative arthritis is rated on limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Under Diagnostic Code 5215, limitation of motion in dorsiflexion or palmar flexion of either wrist to less than 15 degrees or where palmar flexion is limited in line with the forearm warrants a 10 percent rating. A 10 percent rating is the highest rating available under this Diagnostic Code. 38 C.F.R. § 4.71a. Under Diagnostic Code 5214, ankylosis of the major wrist is evaluated as 30 percent disabling when there is evidence of ankylosis of the wrist between 20 and 30 degrees of dorsiflexion. Id. Ankylosis is the "immobility and consolidation of a joint due to disease, injury, surgical procedure." Lewis v. Derwinski, 3 Vet. App. 259 (1992). For VA purposes, normal dorsiflexion of the wrist is from 0 to 70 degrees, and normal palmar flexion is from 0 to 80 degrees. Normal radial deviation of the wrist is from 0 to 20 degrees, and normal ulnar deviation is from 0 to 45 degrees. 38 C.F.R. § 4.71, Plate I (2012). The Veteran underwent VA examination in January 2008 at which time the examiner noted that the appellant could be experiencing some grip strength deficit in the right hand due to possible early osteoarthritis of that joint causing some discomfort. Notably, there was no x-ray evidence of osteoarthritis. The Veteran demonstrated full range of wrist motion. X-rays completed in December 2009 were unremarkable; and x-rays completed in January 2012 showed no arthritis. At a December 2009 VA examination the appellant demonstrated right wrist dorsiflexion to 50 degrees, palmar flexion to 45 degrees, radial deviation to 15 degrees, and ulnar deviation to 25 degrees. Although there was objective evidence of pain following repetitive motion, there was no additional limitation of motion after three repetitions. The examiner found no joint ankylosis. The Veteran underwent VA examination in January 2012 at which time he demonstrated right wrist palmar flexion to 55 degrees with pain at 45 degrees, and dorsiflexion to 60 degrees with pain at 50 degrees. The Veteran was able to perform repetitive-use testing at which time he demonstrated right wrist palmar flexion at 55 degrees and dorsiflexion to 60 degrees. There was no joint ankylosis. The examiner found no additional limitation of wrist motion following repetitive testing although there was functional impairment of the right wrist described as less movement than normal, weakened movement, and pain on movement. Comparing these manifestations to the rating criteria, the Board finds that the criteria in excess of a 10 percent evaluation are not more nearly approximated. As noted above, a higher rating is not available under 38 C.F.R. § 4.71a, Diagnostic Code 5215, but is available under Diagnostic Code 5214. This latter Diagnostic Code, however, requires the presence of ankylosis, a manifestation not present in the Veteran's case. Again, ankylosis is "immobility and consolidation of a joint due to disease, injury, surgical procedure." As the Veteran has consistently demonstrated right wrist motion, albeit painful, there is no evidence of ankylosis. As such, entitlement to a higher evaluation is not warranted under Diagnostic Code 5214. Furthermore, in considering the applicability of other diagnostic codes, the Board finds that no other Diagnostic Code is applicable for this wrist disorder. In this regard the Diagnostic Codes discussed above are the only codes which specifically address a limitation of wrist motion. The Board has also considered whether a higher disability evaluation is warranted due to functional loss due to pain or due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40 , 4.45, 4.59. See DeLuca v. Brown, 8 Vet. App. 202 (1995). However, none of the evidence has demonstrated an additional compensable limitation in range of motion after repetitive-use testing. That is, while pain causes a decreased range of motion, that decrease is not so severe as to be manifested by ankylosis. Thus, the Board finds that any symptoms associated with the Veteran's disability are encompassed in the current evaluation. Id., 38 C.F.R. §§ 4.40 , 4.45, 4.59. The evidence does not contain factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal. The assignment of staged ratings is therefore not warranted. After considering all the evidence of record, the Board finds that the preponderance of it is against the claim. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C.A. § 5107. Thus, entitlement to an evaluation greater than 10 percent for residuals of a right wrist fracture with osteoarthritis is denied. Decreased Right Hand Grip Strength The Veteran seeks entitlement to an evaluation in excess of 30 percent for decreased right hand grip strength. The 30 percent rating for this disorder was assigned by analogy to 38 C.F.R. § 4.124a, Diagnostic Code 8514. Under Diagnostic Code 8514, moderate incomplete paralysis of the musculospiral nerve (radial nerve) of the major extremity warrants a 30 percent disability rating. Severe incomplete paralysis of the major extremity warrants a 50 percent disability rating. The term "incomplete paralysis," with this and other peripheral nerve injuries, indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a. At the January 2008 VA examination, the Veteran demonstrated right hand grip strength of 30 kilograms as compared to a left hand grip strength of 40 to 50 kilograms. At the December 2009 VA examination, the Veteran demonstrated right hand grip strength of 40 kilograms as compared to a left hand grip strength of 105 kilograms. The examiner noted tenderness, weakness, and guarding of movement. At the January 2012 VA peripheral nerve examination, the Veteran reported moderate intermittent pain and mild right upper extremity numbness. Muscle strength testing demonstrated active movement against some resistance (4/5) on right wrist flexion, right wrist extension, and right thumb to index finger pinch; as well as active movement against gravity (3/5) on right grip. The examiner noted that grip strength measured with hydraulic dynamometer on the right was 20 pounds. Reflex examination was normal in the right upper extremity. Sensory examination demonstrated decreased sensation to light touch in the right hand/fingers. The examiner noted that the Veteran could not identify pinprick pain sensations in the fourth and fifth fingers in both the palmar and dorsal aspects of the right hand. Phalen's sign and Tinel's sign were negative. The examiner opined that the Veteran had moderate incomplete right radial nerve paralysis. The findings associated with the Veteran's decreased right hand grip strength most closely correlate to the currently assigned 30 percent rating for moderate incomplete paralysis. In this respect the Veteran contends that his right radial nerve impairment, without consideration of the impairment of the ulnar nerve, is severely disabling. The medical evidence, however, to particularly include the January 2012 VA examiner's opinion, is of greater probative than the Veteran's lay opinion. As noted above, the VA examiner determined that the Veteran had no more than moderate incomplete paralysis of the right radial nerve. While physical examinations of the right upper extremity showed a decreased grip strength between 2008 and 2012, and decreased sensation, reflexes in that extremity were opined to be normal. Further Phalen's sign, i.e., a test for carpal tunnel syndrome was negative; and Tinel's sign, a test for nerve irritation, was also negative. In light of these findings, the Board concludes that the preponderance of the evidence is against finding evidence of severe incomplete paralysis of radial nerve. Thus, entitlement to an increased evaluation is not warranted. The evidence also does not contain factual findings showing distinct time periods in which this disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal. The assignment of staged ratings is therefore not warranted. After considering all the evidence of record, the Board finds that the preponderance of it is against the claim. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C.A. § 5107. Thus, the claim for an evaluation greater than 30 percent for a disability manifested by decreased grip of the right hand is denied. PTSD The Veteran seeks entitlement to an evaluation in excess of 50 percent for PTSD. Under the General Rating Formula for Mental Disorders, 38 C.F.R. § 4.130, Diagnostic Code 9411-9440, a 50 percent evaluation requires occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete task); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted for occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, judgment, thinking or mood, due to such symptoms as: suicidal ideation; obsessional rituals that interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting 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); and inability to establish and maintain effective relationships. 38 C.F.R. § 4.130. The specified factors for each incremental psychiatric rating are not requirements for a particular rating but are examples providing guidance as to the type and degree of severity, or their effects on social and work situations. Thus, any analysis should not be limited solely to whether the symptoms listed in the rating scheme are exhibited; rather, consideration must be given to factors outside the specific rating criteria in determining the level of occupational and social impairment. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). The global assessment of functioning score is a scaled rating reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health illness." See American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM -IV). According to this Manual a global assessment of functioning score of 71 to 80 indicates the examinee has, if at all, symptoms that are transient or expectable reactions to psychosocial stressors but no more than slight impairment in social, occupational or school functioning. A global assessment of functioning score of 61 to 70 indicates the examinee has some mild symptoms or some difficulty in social, occupational, or school functioning, but generally functions pretty well with some meaningful interpersonal relationships. A global assessment of functioning score of 51 to 60 indicates the examinee has moderate symptoms or moderate difficulty in social, occupational, or school functioning. A global assessment of functioning score of 41 to 50 indicates the examinee has serious symptoms or a serious impairment in social, occupational, or school functioning. An August 2008 private psychological evaluation prepared for the representative noted that the Veteran reported that it was difficult to discuss his PTSD symptoms. He became tearful, shaken, and tremulous. He endorsed numerous items that were consistent with symptoms of anxiety and his mental content consisted of feelings of depression, sadness, a lack of joy in life, an inability to relax, and unhappiness with himself. There were no obvious indications of psychotic distortions, including ideas of reference, hallucinations, faulty perceptions or misinterpretations of consensual reality. The Veteran admitted to having occasional suicidal thoughts. He displayed normal cognitive function and his memory appeared to be intact. His insight and judgment also appeared to be intact. The psychologist diagnosed the Veteran as having PTSD, major depression, and a generalized anxiety disorder. The examiner assigned a global assessment of functioning score of 52 and noted "Depressed man, chronic pain, panic attacks, problems in several areas of functioning." The Veteran underwent VA examination in January 2009 at which time he was tearful at times, and his affect was serious with no apparent broadening. His mood was anxious and depressed. The appellant's attention was intact, and he was oriented to person, time, and place. There was no impairment of thought process or communication, and his memory was normal. His thought content was unremarkable, and he displayed no delusions. The Veteran reportedly understood the outcome of his behavior. The Veteran reported that he usually got five or so hours of sleep a night, but some nights he reported getting far less than two hours. He had no hallucinations, inappropriate behavior, or obsessive/ritualistic behavior. The Veteran denied homicidal thoughts but admitted to weekly suicidal thoughts without plan or intent. The Veteran further stated that while he thought about suicide he would never do anything like that. The Veteran stated that he became angry and irritable but was able to control it and that he sometimes got emotional when driving if thoughts of Iraq surfaced. The examiner noted that the Veteran reported decreased concentration, increased absenteeism, poor social interaction, and that he avoided some people. The diagnosis was PTSD, and a global assessment of functioning score of 58 was assigned. An April 2009 Behavioral Health Lab Consult indicated that the Veteran reported depressive symptoms such as little interest or pleasure, feeling down or hopeless, trouble sleeping, being tired, low energy, feelings of failure, and trouble concentrating. He also reported feeling agitated which made it somewhat difficult to do work, take care of things at home, and get along with others. The Veteran reported symptoms of anxiety such as disturbing memories, disturbing dreams, being extremely upset, avoiding thoughts and activities, trouble with recall, loss of interest, feeling distant, feeling numb, and feeling life is shortened. He also described feeling irritable, difficulty concentrating, feeling nervous, and being easily startled. The Veteran reported that during the prior year he had thoughts that life was not worth living, that he wished he were dead, and that he thought about taking his own life. The Veteran, however, also advised that during the prior year he never seriously considered suicide or made an attempt at committing suicide. The examiner noted that the Veteran reported no psychotic symptoms or manic/hypomanic symptoms. A little more than a week later, the Veteran was seen for an initial mental health assessment in which he reported having episodes of dysphoria two to three times a week accompanied by irritability, decreased patience, and anhedonia. The Veteran reported noticeable diminished concentration. He denied other symptoms, nightmares, flashbacks, as well as suicidal or homicidal ideation. On mental status examination, the Veteran was fidgety, his eye contact was good, and his mood was "alright." His affect was mildly blunted. His thought process revealed no flight of ideas or loosening association and his thought content revealed no hallucinations, delusions, or paranoia. His speech was spontaneous, noncircumstantial, and nontangential. There was no evidence of internal stimulation or ideas of reference. He had no plan to harm himself or others. He was aware of himself and his surroundings. Concentration and attention were average, and his fund of knowledge had adequate insight. Fair reality testing was good. After mental status examination, the examiner diagnosed the Veteran with PTSD and depressive disorder and assigned a global assessment of functioning score of 55. In June 2009, the Veteran reported that he had been fully compliant with his medication that that he was feeling more patient and less irritable, that his nightmares and flashbacks were less frequent and less intense, and that he was sleeping better. He was able to redirect his attention away from worry. It was noted that the Veteran had not used alcohol since his last appointment, and he saw the benefit of abstaining. He denied suicidal and homicidal ideation. Mental status examination noted no abnormality. The clinical assessments were posttraumatic stress disorder, a depressive disorder, and alcohol abuse. In August 2009, the Veteran reported that with medication, he was less irritable, more patient, had a better sense of humor, and his nightmares were almost absent. The Veteran reported no new psychosocial stressors and that he was getting along well at work. The Veteran denied suicidal or homicidal ideation as well as symptoms of mania or psychosis. His speech was spontaneous, noncircumstantial and nontangential. He used good eye contact and was appropriately attired. His affect was appropriate to his mood. Comparing the manifestations of the Veteran's PTSD prior to December 2011 to the rating criteria, the criteria in excess of a 50 percent evaluation are not more nearly approximated. As noted above, in order to warrant an evaluation of 70 percent, the Veteran would need to demonstrate occupational and social impairment with deficiencies in most areas, such as work, family relationships, judgment, thinking or mood, due to such symptoms as: suicidal ideation; obsessional rituals that interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting ability to function independently, appropriately and effectively; impaired impulse; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances; and an inability to establish and maintain effective relationships. The evidence does not support such a conclusion. Although the Veteran reported suicidal ideation during the term he never reported having a plan or intent. In addition, global assessment of functioning scores assigned prior to December 19, 2011, maintained a consistent range between 52 and 58, i.e., they were indicative of moderate symptoms or moderate difficulty in social, occupational, or school functioning. Such scores are consistent with the Veteran's PTSD symptoms prior to December 19, 2011. There is no evidence of obsessional rituals during this term, and the appellant's speech was consistently described as normal. There is no evidence that the appellant was unable to function independently, that he suffered from spatial disorientation, or that he neglected his own personal appearance and/or hygiene. After considering all the evidence of record, the Board finds that the preponderance of the most probative evidence is against the claim. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. 38 U.S.C.A. § 5107. Thus, entitlement to an evaluation greater than 50 percent for PTSD for the appeal period prior to December 19, 2011 is denied. Extraschedular ratings In reaching these decisions concerning the ratings warranted for the disorders at issue the Board considered the appellant's entitlement to an extraschedular rating. In this regard, because the disability ratings are averages, "it follows that an assigned rating may not completely account for each individual veteran's circumstance, but nevertheless would still be adequate to address the average impairment in earning capacity caused by disability." Thun v. Peake, 22 Vet. App. 111, 114 (2008). In exceptional cases 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 38 C.F.R. § 3.321, 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). In Thun, the Court fashioned a three-step inquiry for determining whether a Veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the Veteran's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. Applying the facts in this case to the legal criteria set forth above, the Board finds that the preponderance of the evidence is against a referral for extraschedular consideration for the appellant's service-connected right wrist fracture residuals, decreased right hand grip strength, and post traumatic stress disorder. The evidence does not show exceptional or unusual factors which render application of the schedule impractical or inadequate. The Board has compared the level of severity and symptomatology presented by these disorders with the applicable rating criteria and concludes that the rating criteria reasonably describe his disability level and symptomatology. Moreover, there is no evidence that any of these disorders are manifested by a marked interference with employment and frequent periods of hospitalization beyond that contemplated by the currently assigned ratings. Indeed, the record does not show, nor does the appellant contend, that he has ever been hospitalized as a result of these disorders during the appellate term being reviewed. Hence, the Board must conclude that entitlement to an extraschedular rating is not in order for any of the disorders at issue. ORDER Entitlement to an evaluation in excess of 10 percent for residuals of a right wrist fracture with possible early osteoarthritis is denied. Entitlement to an initial evaluation in excess of 50 percent for PTSD from August 5, 2008 to December 18, 2011, is denied. Entitlement to an initial evaluation in excess of 30 percent for a right hand disability manifested by decreased grip strength from November 28, 2007, is denied. REMAND With respect to the issue of entitlement to an increased evaluation for PTSD since December 19, 2011, the Veteran underwent VA examination on that date, however, the examiner did not assign a global assessment of functioning score. As such, if at all possible, it is the Board's opinion a global assessment of functioning score should be obtained based on those examination findings. In addition, at the January 2013 Video Conference Hearing, the Veteran testified that over the prior year, his posttraumatic stress disorder had gotten worse. In fact, a private psychological assessment conducted in September 2012 indicates that the Veteran had been assigned a global assessment of functioning score of 49. As the Veteran last had a VA examination for compensation and pension purposes to determine the severity of PTSD symptoms in December 2011, he should be provided an opportunity to report for a current VA psychiatric examination to ascertain the current status of his service-connected PTSD. Accordingly, the case is REMANDED for the following action: 1. The Veteran should be requested to indicate if he has received any VA or non-VA medical treatment for his PTSD since December 2011. If so, the Veteran should be provided with the necessary authorizations for the release of any treatment records not currently on file. All attempts to procure records identified should be documented in the file. If the RO cannot locate such records, the RO must specifically document the attempts that were made to locate them, and explain in writing why further attempts to locate or obtain any government records would be futile. The RO must then: (a) notify the claimant of the specific records that it is unable to obtain; (b) explain the efforts VA has made to obtain that evidence; and (c) describe any further action it will take with respect to the claims. The claimant must then be given an opportunity to respond. 2. Thereafter, the Veteran should be afforded a VA examination to ascertain the severity of his PTSD since December 19, 2011. The claims file, to include the appellant's Virtual VA eFile must be made available to and reviewed by the examiner in conjunction with the examination. The examination report should reflect that such a review was made. All pertinent symptomatology and findings should be reported in detail. Any indicated diagnostic tests and studies should be accomplished. The examination must address the nature and extent of the appellant's posttraumatic stress disorder, and assign a global assessment of functioning score. Moreover, the VA examiner is requested to assign a global assessment of functioning score based on findings from the December 19, 2011, VA examination. 3. The Veteran is to be notified that it is his responsibility to report for the examination 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 the aforementioned 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. 4, After the development requested has been completed, the RO should review the examination report to ensure that it is in complete compliance with the directives of this REMAND. The AMC/RO must ensure that the examiners documented their consideration of Virtual VA. If any report is deficient in any manner, the RO must implement corrective procedures at once. 5. The case should then be reviewed on the basis of the additional evidence. If the benefit sought is not granted in full, the Veteran should be furnished a Supplemental Statement of the Case and be afforded a reasonable opportunity to respond before the record is returned to the Board for further review. 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). ______________________________________________ DEREK R. BROWN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs