Citation Nr: 1339504 Decision Date: 12/02/13 Archive Date: 12/13/13 DOCKET NO. 13-18 877 ) DATE ) ) On appeal from the Department of Veterans Affairs Medical and Regional Office Center in Wichita, Kansas THE ISSUES 1. Entitlement to an increased evaluation for posttraumatic stress disorder currently rated 30 percent disabling. 2. Entitlement to an increased evaluation for post-operative residuals of left (non-dominant) arm fractures status post open reduction internal fixation of fractures of the radius and ulna, and closed reduction of humeral fracture, with residual scars, currently rated 20 percent disabling. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD D. Schechter, Counsel INTRODUCTION The Veteran served on active military duty from April 2002 to September 2004. The appeal comes before the Board of Veterans' Appeals (Board) from a June 2011 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Wichita, Kansas. By that rating action the RO granted an increased evaluation to 30 percent for posttraumatic stress disorder (PTSD), effective from August 24, 2010. This rating action recharacterized the Veteran's service-connected mental disorder as PTSD based on psychiatric findings. The disorder was characterized as an adjustment disorder with anxious mood when first granted service connection. The appeal is remanded to the RO via the Appeals Management Center in Washington, DC. REMAND The record reflects that the Veteran was to have been afforded VA examinations in April 2013 to assess the current status of his service-connected disabilities the subject of this appeal. However, a telephonic contact attempt failed, and a letter sent to the Veteran elicited no response. The Veteran's authorized representative in an Informal Hearing Presentation submitted in August 2013 referenced scheduling difficulties involving an incorrect telephone number. Indeed, a review of the record reflects that the current telephone contact number and home address of the Veteran which he provided on his VA Form 9 submitted in June 2013 are different from those used by the VA in attempting to schedule these examinations. The Veteran and his representative have claimed worsening of the Veteran's claimed disabilities, warranting current examinations. The Veteran is noted to have been most recently evaluated for his PTSD by an October 2010 VA examination, and to have not been evaluated for his residuals of left arm fractures since his was first service connection for these residuals in September 2004. Treatment records in the evidence of record include a September 2010 private treatment evaluation of the left arm residuals. The treating private physician, P.B., raised the possibility of the Veteran having reflex sympathetic dystrophy of that upper extremity, potentially associated with the service-connected residuals of fractures. This question of additional disability should be addressed upon remand examination. Accordingly, the case is remanded for the following action: 1. The RO must contact the Veteran and afford him the opportunity to identify or submit any additional pertinent evidence in support of his claim. Appropriate efforts should be made to contact him at his most recent address of record, which, at the time of the Board's drafting, was listed on his VA Form 9 submitted in June 2013. Based on his response, the RO must attempt to procure copies of all records which have not previously been obtained from identified treatment sources. Regardless of his response, the RO must attempt to obtain records of treatment received at indicated VA facilities. When requesting records not in the custody of a Federal department or agency, such as private treatment records, the RO must make an initial request for the records and at least one follow-up request if the records are not received or a response that records do not exist is not received. All attempts to secure this evidence must be documented in the claims file by the RO. If the RO is unable to secure any of the identified records, the RO must notify the Veteran and (a) identify the information the RO is unable to obtain; (b) briefly explain the efforts that the RO made to obtain that information; (c) describe any further action to be taken by the RO with respect to the claim; and (d) that the Veteran is ultimately responsible for providing information. The Veteran and his representative must then be given an opportunity to respond. 2. Thereafter, the Veteran must be afforded a VA examination by an appropriate specialist to address the nature and severity of his service-connected post-operative residuals of radius, ulnar, and humeral fractures of the left arm, status post open reduction internal fixation of the radius and ulna and closed reduction of the humeral fracture, with residual scars. The specialist should have adequate expertise to address not only the musculoskeletal fracture residuals, but also any associated neuropathy and any associated reflex sympathetic dystrophy which may have developed. The claims file and all electronic records, including any additional evidence obtained, must be made available to the examiner for review. All tests and studies deemed necessary by the examiner must be conducted. The tests and studies performed, and their results, must be included and discussed in the examination report. The examiner must record pertinent medical complaints, symptoms, and clinical findings, including range of motion, and comment on the functional limitations, if any, caused by the left upper extremity fractures and their residuals. Specifically, the examiner should also address any reflex sympathetic dystrophy or other secondary condition which may have arisen due to these service-connected disorders. In so doing, the examiner should address the question of reflex sympathetic dystrophy as raised by a private September 2010 treatment record, by Dr. P.B., contained within the claims folder. The examiner should also address any associated limitation of motion of the left arm as a residual of these fractures, using a goniometer and noting by comparison the normal range of motion, with standard or other-arm (contralateral) ranges provided for comparison purposes. If pain is present on any motion, the Veteran must be instructed to indicate to the examiner at what degree the pain begins and the examiner must report this finding. The examiner must address whether there is any weakened movement, incoordination, excess fatigability, or pain on movement as a result of the Veteran's service-fracture residuals. The functional impairment due to weakened movement, incoordination, excess fatigability, or pain on movement must, if feasible, should be assessed in terms of additional degrees of limitation of motion lost. The examiner should also address the status of residual scars, including surgical scars, addressing any pain, instability, keloid, deep scarring, adherence to underlying tissues, or impact on functioning of affected parts. With respect to any subjective complaints of pain, the examiner must comment on whether pain is visibly manifested on movement of the affected part, the presence and degree of, or absence of, muscle atrophy attributable to the service-connected fracture residuals, the presence or absence of changes in condition of the skin indicative of disuse, and the presence or absence of any other objective manifestations that would demonstrate disuse or functional impairment due to pain attributable to the fracture residuals. The examiner must specifically state whether any neurologic symptoms found are caused by the Veteran's service-connected residuals of left arm fractures. The examiner should address whether reflex sympathetic dystrophy is present, and if so whether it is attributable to the Veteran's service-connected residuals of left arm fractures. If any such (or any other) additional attributable residuals or secondary effects are found, the examiner should fully address their nature and extent, including impacts on functioning of affected parts and functioning of the Veteran as a whole. If the examiner is not qualified to address such additional impairments, then an addition examination by an appropriate specialist to address these should be obtained. The examiner must also address the degree to which the Veteran's service-connected residuals of left arm fractures impact his capacity to obtain or sustain gainful employment. Relevant findings and analysis must be provided. 3. The Veteran must be afforded a VA examination by a psychiatrist, to address the nature and severity of his service-connected PTSD, originally characterized as adjustment disorder with anxious mood, and thus encompassing psychiatric impairment attributable to PTSD or adjustment disorder with anxious mood. The claims file and all electronic records, including any additional evidence obtained, must be made available to the examiner for review. The examiner must comment upon the presence or absence, frequency, and severity of the Veteran's service-connected PTSD and any adjustment disorder with anxious mood. Manifestations to include impact on functioning should be addressed, to include the following: affect; speech; panic attacks; ability to understand complex commands; short- and long-term memory; judgment; abstract thinking; motivation; mood; ability to establishing and maintaining effective work and social relationships; suicidal and/or homicidal ideations; obsessional rituals; ability to function independently, appropriately, or effectively; impulse control; neglect of personal appearance and hygiene; ability to adapt to stressful circumstances; delusions or hallucinations; general behavior; persistent danger of hurting self or others; ability to perform activities of daily living; and orientation. The examiner must also enter a complete multi-axial evaluation, and assign a Global Assessment of Functioning score, together with an explanation of what the score represents in terms of his psychological, social, and occupational functioning. The examiner must provide detailed findings as to the nature and scope of disability due to the Veteran's PTSD and/or adjustment disorder with anxious mood, including whether the Veteran is precluded from obtaining or maintaining substantially gainful employment due to his PTSD and/or adjustment disorder with anxious mood. If another psychiatric disability present is not differentiable in its symptoms from the Veteran's PTSD or adjustment disorder with anxious mood, then the examiner must address the nature and scope of the entirety of the Veteran's psychiatric disabilities, including whether they, taken as a whole, preclude him from obtaining or maintaining substantially gainful employment. 4. The RO must notify the Veteran that it is his responsibility to report for the examinations, and to cooperate in the development of the claims. 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 (2013). In the event that the Veteran does not report for any scheduled examinations, documentation must be obtained and associated with the Veteran's claims file that shows that notice scheduling the examination was sent to his last known address. Documentation must be also be obtained and associated with the Veteran's claims file demonstrating any notice that was sent was returned as undeliverable, if that is the case. 5. After completing the above actions, and any other development as may be indicated by any response received as a consequence of the actions taken above, the claims on appeal must be readjudicated. If any benefit sought on appeal is denied, a supplemental statement of the case must be provided to the Veteran and his representative. After the Veteran and his representative have had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. No action is required by the Veteran until he receives further notice; however, he may present additional evidence or argument while the case is in remand status at the RO. Kutscherousky v. West, 12 Vet. App. 369 (1999). _________________________________________________ JOY A. MCDONALD 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) (2013).