Citation Nr: 1327941 Decision Date: 09/03/13 Archive Date: 09/10/13 DOCKET NO. 09-22 143 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to an initial rating in excess of 10 percent for service-connected systemic lupus and rheumatoid arthritis. 2. Entitlement to an initial rating in excess of 10 percent prior to June 4, 2009, and in excess of 40 percent thereafter, for service-connected Raynaud's syndrome. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD A. Barner, Associate Counsel INTRODUCTION The Veteran had active military service from November 1986 to November 2006. This matter comes to the Board of Veterans' Appeals (Board) from an August 2007 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Huntington, West Virginia. Jurisdiction was subsequently transferred to the RO in St. Petersburg, Florida. It is noted that as of the most recent rating action on file, appellant has a combined 100 percent evaluation for her multiple service connected disorders. Special Monthly Compensation (SMC) at the rate provided by 38 U.S.C.A. § 1114(s) has also been assigned. SMC has also been awarded for the loss of a creative organ. Review of Virtual VA reveals that currently there are no medical records located there that are not also in the claims folder. The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if further action is required. REMAND The Veteran was afforded a VA examination in April 2007 for her systemic lupus and rheumatoid arthritis and Raynaud's syndrome. The examiner indicated that concerning Raynaud's there was mild, bilateral involvement of the distal fingertips. The Veteran's rheumatoid arthritis was manifested by pain in the upper and lower extremities bilaterally, described as constant. The Veteran was prescribed Hydroxychloroquine, with a history of prior oral Prednisone use. Since her examination, there are private treatment records that suggest worsening symptoms. Dermatologically, in January 2008 the Veteran experienced boils on the back of her thigh, and in October 2008 there was mild sclerodactyly on her fingers. Musculoskeletal system symptoms include bone pain in her hip in December 2007. In April 2008 there was pain and swelling in her arm, and in June 2008 she was reportedly unable to abduct her left arm more than 90 degrees, experienced pain in her left axilla, and difficulty raising her arm. In July 2008 the Veteran experienced sore trigger points. In January 2009 the Veteran experienced pain in her feet, neck, back, legs and hands. In July 2008 the Veteran experienced cardiac symptoms to include a mildly enlarged heart, with small pericardial effusion. Regarding her pulmonary system, there was mild reduction diffusion capacity in March 2007. The Veteran had an episode of pneumonia in February 2008, during which time she was undergoing chemotherapy. Her renal system symptoms include in November 2007 blood urea nitrogen to creatinine level of 28, or high. Hematological symptoms include an episode of anemia in February 2008, during which time she was undergoing chemotherapy. Neuropsychiatric symptoms include headaches in December 2007, also during which time she was undergoing chemotherapy. Neurological symptoms include tingling in her hands and feet in May 2008. Systemic symptoms include feelings of tiredness, fatigue, weakness, feeling poorly and malaise in 2007 and 2008. The Veteran's lymph nodes on the left were enlarged in June 2008. The rating for her Raynaud's syndrome was increased as of June 4, 2009, the date of a statement received from a private physician received with her substantive appeal. In that statement it was also indicated that the appellant was also seeing a rheumatologist. It does not appear that those records, or any other records, of ongoing treatment have been obtained. It is unclear whether she may have active rheumatoid arthritis, or what exactly chronic residuals might exist. The record is insufficient to ascertain whether there are bases to assign separate ratings for the rheumatoid arthritis and the lupus. In light of the passage of time, in combination with private treatment records showing that the Veteran has experienced numerous symptoms that may be associated with her systemic lupus or rheumatoid arthritis, or even Raynaud's, and which were not discussed at her April 2007 examination, remand is necessary. Accordingly, the case is REMANDED for the following action: 1. Contact the appellant and obtain information, including releases as needed, to obtain records of all pertinent VA and private medical treatment. The rheumatologist noted in the June 2009 letter should be identified and records obtained, in part to determine whether there has been recent active rheumatoid arthritis. Records from all other private and VA sources should be obtained as identified. If an attempt to obtain records is unsuccessful, documentation of attempts made should be associated with the claims folder. 2. Thereafter, and whether records are obtained or not, schedule the Veteran for appropriate VA examination(s) to determine the nature and severity of her systemic lupus, rheumatoid arthritis, and Raynaud's syndrome. The claims folder, to include access to Virtual VA (if any pertinent records are added to it), must be available to, and reviewed by the examiner(s). All indicated tests should be accomplished and all clinical findings should be reported in detail. Specifically, it should be determined if there has been clinically active rheumatoid arthritis during the appeal period. Following examination, to include all indicated tests, the examiner is asked to: (a) Identify all symptoms associated with the Veteran's systemic lupus, rheumatoid arthritis, and Raynaud's disease. To the extent possible, identify which symptoms are manifestations of systemic lupus and rheumatoid arthritis, or Raynaud's syndrome, or which are overlapping symptoms. Please set out symptoms that do not overlap but are specific to one of the disorders. (b) Address symptoms according to the bodily system affected. (c) Describe whether there have been exacerbations of the lupus and or characteristic attacks of the Raynaud's syndrome, and the frequency thereof. Please detail the symptoms present in the exacerbations and characteristic attacks. (d) Please indicate whether the rheumatoid arthritis has been active, either on this exam, or whether records reveal episodes of past activity. If not active, please describe any chronic residuals to include limitation of motion of any joints, of other such residuals. The examiner(s) must provide a comprehensive report including complete rationales for all opinions and conclusions reached, citing the objective medical findings leading to the conclusions. 3. After the development requested, review the examination report to ensure that it is in compliance with the directives of this REMAND. If the report is deficient in any manner, implement corrective procedures. 4. After undertaking any additional development deemed appropriate, adjudicate the Veteran's claim in light of any additional evidence added to the record. Consideration should be given as to whether separate ratings for lupus and rheumatoid arthritis. If any benefit sought on appeal remains denied, the Veteran and her representative should be furnished with 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). _________________________________________________ MICHAEL D. LYON Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2012).