Citation Nr: 1401411 Decision Date: 01/13/14 Archive Date: 01/31/14 DOCKET NO. 08-23 321 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia THE ISSUES 1. Entitlement to an initial evaluation in excess of 10 percent for carpal tunnel syndrome, left hand. 2. Entitlement to an initial compensable evaluation for left middle finger fracture. 3. Entitlement to an initial compensable evaluation for a skin disability of the back. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Suzie S. Gaston, Counsel INTRODUCTION The Veteran served on active duty from August 1998 to December 2006. This matter came before the Board of Veterans' Appeals (Board) on appeal from rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia. By a rating action in April 2007, the RO granted service connection for a skin disability of the back and service connection for left long finger fracture, both evaluated as 0 percent disabling, effective from December 4, 2006. Subsequently, in a rating action dated in January 2010, the RO granted service connection for carpal tunnel syndrome, left hand, evaluated as 10 percent disabling, effective September 9, 2009. The Veteran perfected a timely appeal of the ratings assigned to his service-connected disabilities. On September 17, 2013, the Veteran appeared and testified at a hearing before the undersigned Veterans Law Judge in Washington, D.C. A transcript of the hearing is of record. At the hearing, the Veteran submitted additional evidence for which he has provided written waiver of RO review under 38 C.F.R. § 20.1304 (2013). (The issues of entitlement to compensable evaluations for left middle finger fracture and a skin disability of the back are addressed in the remand that follows the decision below.) FINDING OF FACT The Veteran's carpal tunnel syndrome of the left hand more closely approximates moderate incomplete paralysis of the median nerve. CONCLUSION OF LAW The criteria for an initial evaluation of 20 percent, but no more, for carpal tunnel syndrome of the left (minor) hand have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.124, 4.124a, Diagnostic Code 8515 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION I. Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) enhanced VA's duty to notify and assist claimants in substantiating their claims for VA benefits, as codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.159, 3.326(a) (2013). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant of the information and evidence not of record that is necessary to substantiate the claim; and to indicate which information and evidence VA will obtain and which information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). The United States Court of Appeals for Veterans Claims (Court) has held that VCAA notice should be provided to a claimant before the initial RO decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). However, if VCAA notice is provided after the initial decision, such a timing error can be cured by subsequent readjudication of the claim, as in a statement of the case (SOC) or supplemental SOC (SSOC). Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). In this case, VA satisfied its duty to notify by means of a letter dated in September 2009 from the RO to the Veteran, which was issued prior to the RO decision in January 2010. That letter informed the Veteran of what evidence was required to substantiate the claim and of his and VA's respective duties for obtaining evidence. The Board finds that the content of the above-noted letter provided to the Veteran complied with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) regarding VA's duty to notify. Regarding the duty to assist, the Veteran was provided an opportunity to submit additional evidence. It also appears that all obtainable evidence identified by the Veteran relative to his claim has been obtained and associated with the claims file, and that neither he nor his representative has identified any other pertinent evidence not already of record that would need to be obtained for a proper disposition of the issues decided herein. The Board is unaware of any outstanding evidence or information that has not already been requested with respect to the issue on appeal. The Veteran has been afforded VA examinations on the issue decided herein. McLendon v. Nicholson, 20 Vet. App. 79 (2006). The examinations afforded the Veteran are adequate. Nieves-Rodriguez v. Peake, 22 Vet. App 295 (2008). The examinations were conducted by medical professionals who reviewed the medical records, solicited history from the Veteran, and examined the Veteran. Accordingly, the Board finds that VA has satisfied its duty to notify and assist the Veteran in apprising him as to the evidence needed, and in obtaining evidence pertinent to his claims under the VCAA. Therefore, no useful purpose would be served in remanding this matter for yet more development. Such a remand would result in unnecessarily imposing additional burdens on VA, with no additional benefit flowing to the Veteran. The Court has held that such remands are to be avoided. Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). II. Background The service treatment records reflect that the Veteran was seen in October 1998 for complaints of pain from a cut to the left middle finger; he stated that a dumpster fell on his finger as he was disposing trash. The assessment was trauma to the left middle finger. A report of medical history, dated in July 2002, reflects complaints of bilateral hand numbness. He was treated for left middle finger laceration. In October 2006, the Veteran presented with complaints of right elbow pain with onset during military maneuvers; he also complained of numbness of his fingers. On the occasion of the separation examination in October 2006, the Veteran reported a loss of feeling in the finger of his left hand due to an injury in boot camp. No pertinent diagnosis was noted. The Veteran's initial claim for service connection (VA Form 21-526) was received in March 2007. The Veteran was afforded a VA compensation examination in March 2007. On examination of the fingers, flexors had strength 5/5, abduction was 5/5, and thumb opposition was 5/5. There was no muscle atrophy of the left hand or fingers and secondary examination in the left hand was normal. The Veteran was afforded another VA examination in June 2009. The Veteran reported having carpal tunnel syndrome bilaterally, which had been present for 8 years; he reported problems with tingling and numbness of the fingers at all three sections of the digit. The Veteran also reported weakness of the fingers. The Veteran indicated that he experiences those symptoms every day and they are constant; he stated that the symptoms are worse at night. The Veteran noted that the carpal tunnel affects both hands at rest and while active. He also stated that he was not receiving any treatment for his condition, and he does not experience any functional impairment from this condition. The Veteran described the residuals of numbness, tingling, weakness, and an inability to grasp or hold objects sometimes. The Veteran also reported that he experiences numbness in his hand with both hands having carpal tunnel syndrome. The Veteran stated that he does not experience any functional impairment from his condition. On examination, range of motion of the wrist, bilaterally, was reported to be normal, with 70 degrees of dorsiflexion, 80 degrees palmar flexion, 20 degrees of radial deviation and 45 degrees of ulnar deviation. On the left, the joint function was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use. The examiner noted that the Veteran was able to tie his shoelaces without difficulty. He had difficulty fastening buttons with both hands. He was able to pick up a piece of paper and tear it without difficulty. Hand dexterity examination revealed the left hand fingertips can approximate the proximal transverse crease of the palm. His left hand strength was within normal limits. On the left, the joint function was not additionally limited by pain, fatigue, weakness, lack of endurance or incoordination after repetitive use. Coordination was within normal limits. On neurological evaluation of the upper extremities, motor function was abnormal with findings of the grip strength in both hands normal. Sensory function was abnormal with findings of near absent sensation on the right fingers. The findings were more pronounced on the thumb and the next 3 fingers. The left upper extremity reflexes revealed biceps jerk 2+ and triceps jerk 2+. Examination of the hands and wrists revealed Tinel's sign was present bilaterally; Phalen's test was positive bilaterally. There was motor dysfunction demonstrated by slight decreased grip strength on the right hand. There was sensory dysfunction demonstrated by decreased sensation on the right and left hands, particularly on the fingers. X-ray study of the left hand was within normal limits. The pertinent diagnoses were carpal tunnel syndrome bilaterally. As a carpenter, the Veteran frequently drops things due to weakness in his hands and wrist; he has increased numbness and pain with normal daily activities. Received in August 2009 were VA progress notes dated from June 2008 to December 2008. These records show that the Veteran received ongoing clinical attention for carpal tunnel right hand, status post-surgery. The Veteran was afforded another VA examination in November 2009. The Veteran reported carpal tunnel syndrome bilaterally, which had been present for 4 years. The Veteran reported problems with tingling and numbness of the fingers at the first 4 1/2 fingers. He stated that he has weakness of the fingers in the whole hand. The Veteran reported that the symptoms were constant. He noted that the numbness depended on how the hand is positioned or used. He further noted that the weakness was present all the time and continued to worsen. It was noted that the Veteran was not receiving any treatment for his condition. The Veteran indicted that he has been shocked in the left hand. The Veteran stated that he is a physical laborer and is unable to perform some tasks due to weakness in the hand. There was no evidence of hand tremor on examination. Range of motion of the wrist, bilaterally, was reported to be normal, with 70 degrees of dorsiflexion, 80 degrees palmar flexion, 20 degrees of radial deviation and 45 degrees of ulnar deviation. On the left, the joint function was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use. The Veteran was able to tie his shoelaces, fasten his buttons and pick up a piece of paper and tear it, all without difficulty. Hand dexterity examination revealed the left hand fingertips can approximate the proximal transverse crease of the palm. His left hand strength was within normal limits. On neurological examination of the upper extremities, motor function was within normal limits. Sensory function was abnormal with findings of decreased sensation of fingers 1-3 bilaterally. The left upper extremity reflexes revealed biceps jerk 2+ and triceps jerk 2+. Examination of the hands and wrists revealed Tinel's sign was present bilaterally; Phalen's test was positive bilaterally. There was sensory dysfunction demonstrated by decreased sensation in the fingers in the median nerve distribution. There was no motor dysfunction. The pertinent diagnosis was carpal tunnel syndrome bilateral hands; the objective factors are decreased sensation in the median nerve distribution of the left hand. The effect of the condition on the Veteran's usual occupation is decreased use of the left hand. The effect of the condition on the Veteran's daily activity is decreased function of the left hand with activities requiring normal sensation. The examiner opined that it was at least as likely as not that the Veteran's current bilateral carpal tunnel was a continuation of the treatment received in service regarding hand tingling and numbness. Received in March 2010 was the report from the Neurological Health Associates, reflecting findings of Nerve Conduction Studies, performed in October 2008. This was an abnormal study; it was noted that the pattern suggested a moderate bilateral median neuropathy at the wrist, the right worse than the left. Also received was a progress note from Dr. Fernando Gonzales-Portillo, dated in November 2008, indicating that the Veteran was seen for evaluation of bilateral hand numbness and pain on the left for almost 4 years. The left hand has numbness and tingling sensation at times is throbbing. He recently had a repeat EMG/NCS of both upper extremities that was compatible with moderate bilateral carpal tunnel syndrome. He works taking care of lawns. Motor examination was normal. There was no pronator drift. Muscle strength reflexes were 2+ and symmetric. Following an evaluation, the assessment was carpal tunnel syndrome, doing better, although the numbness bothers him at work as he uses tools that vibrate; and bilateral paresthesia, numbness. He was counseled to avoid repetitive hand movements. At his personal hearing in September 2013, the Veteran's representative noted that the Veteran underwent an examination in November 2008, and the examiner described the carpal tunnel syndrome as being moderate. As a result, it was argued that an increased rating was warranted for the left side under diagnostic code 8515. The Veteran indicated that the doctors tested his arms and elbows with an electric shock to see the extent of the nerve damage in the arm. The Veteran argued that the examination conducted by the Neurological Associates was more complete; he stated that, in November 2009, all the VA doctor did was run his pen across the Veteran's fingers and asked him if he could feel the object. The Veteran maintained that carpal tunnel syndrome only gets better after a release surgery and he has never had one on his left hand; as a result, the condition of the left hand continues to worsen. The Veteran indicated that the experiences tingling, pain, and numbness in the left hand; he also reported a throbbing in the hand at night that wakes him up. The Veteran related that the problems with his left hand affect his everyday life; he stated that he easily drops things. III. Analysis Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (rating schedule). 38 U.S.C.A. § 1155 (West 2002 & Supp. 2013); 38 C.F.R. §§ 4.1, 4.2, 4.10 (2013). If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2013). A disability may require re-evaluation in accordance with changes in a Veteran's condition. It is thus essential, in determining the level of current impairment, that the disability be considered in the context of the entire recorded history. 38 C.F.R. § 4.1. However, where an award of service connection for a disability has been granted and the assignment of an initial evaluation is at issue, separate evaluations can be assigned for separate periods of time based on the facts found. In other words, the evaluations may be "staged." Fenderson v. West, 12 Vet. App. 119, 126 (2001). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.10, 4.40, 4.45. The United States Court of Appeals for Veterans Claims (Court) has held that VA must analyze the evidence of pain, weakened movement, excess fatigability, or incoordination and determine the level of associated functional loss in light of 38 C.F.R. § 4.40, which requires the VA to regard as "seriously disabled" any part of the musculoskeletal system that becomes painful on use. DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions of 38 C.F.R. § 4.14 (avoidance of pyramiding) do not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including during flare-ups. The Board notes that the guidance provided by the Court in DeLuca must be followed in adjudicating claims where a rating under the diagnostic codes governing limitation of motion should be considered. However, the provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45, are to be considered only in conjunction with the Diagnostic Codes predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7 (1996). When all the evidence is assembled, the Board is then responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether the preponderance of the evidence is against the claim, in which case the claim is denied. See 38 U.S.C.A. § 5107(a); 38 C.F.R. § 3.102; and Gilbert v. Derwinski, 1Vet. App. 49, 55 (1990). The Veteran's service-connected carpal tunnel syndrome of the left hand is evaluated pursuant to 38 C.F.R. § 4.124a, Diagnostic Code 8515, which provides that, for both the major and minor side, mild incomplete paralysis of the median nerve warrants a 10 percent evaluation; moderate incomplete paralysis of the median nerve warrants a 20 percent evaluation for the minor side and 30 percent for the major side; and severe incomplete paralysis of the median nerve warrants a 40 percent evaluation for the minor side, and 50 percent for the major. Complete paralysis of the median nerve, with the hand inclined to the ulnar side, the index and middle fingers more extended than normal, considerable atrophy of the muscles of the thenar eminence, the thumb in the place of the hand (ape hand); pronation incomplete and defective, absence of flexion of index finger and feeble flexion of middle finger, inability to make a fist, and the index and middle finger remain extended; inability to flex the distal phalanx of the thumb, defective opposition and abduction of the thumb at the right angle to the palm; weakened flexion of the wrist; and pain with trophic disturbances warrant a 60 percent evaluation for the minor side, and 70 percent for the major. The terms "mild," "moderate," and "severe" are not defined in the Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. The use of terminology such as "moderate" or "severe" by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. The rating schedule provides the following guidance in evaluating the severity of disabilities of peripheral nerves: Neuritis [cranial or peripheral] characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain [at times excruciating] is to be rated on the scale provided for injury of the nerve involved, with a maximum rating equal to severe, incomplete, paralysis. See nerve involved for diagnostic code number and rating. The maximum rating which may be assigned for neuritis not characterized by organic changes referred to in this section will be that for moderate, or with sciatic nerve involvement, for moderately severe, incomplete paralysis. See 38 C.F.R. § 4.123. Neuralgia [cranial or peripheral] characterized usually by a dull and intermittent pain, of typical distribution so as to identify the nerve, is to be rated on the same scale, with a maximum equal to moderate incomplete paralysis. See 38 C.F.R. § 4.124. Handedness for the purpose of a dominant rating will be determined by the evidence of record, or by testing on VA examination. Only one hand shall be considered dominant. 38 C.F.R. § 4.69. The evidence in this case consistently shows that the Veteran is right-handed. Therefore, any left hand disability evaluation will correspond with the minor ratings. As noted above, the service-connected carpal tunnel syndrome of the left hand is currently rated as 10 percent disabling. A 20 percent rating is assigned for moderate incomplete paralysis of the median nerve of the non-dominant hand. Throughout the entire appeal, the Veteran's subjective complaints have included chronic pain, numbness, and tingling in his left hand. At his hearing, the Veteran also reported difficulty with sustained gripping and stiffness in his hand. His complaints are considered credible, competent, and probative of the nature and severity of his condition. On the occasion of the November 2009 VA examination, the VA examiner noted that there was sensory dysfunction demonstrated by decreased sensation in the median nerve in the left hand. It is noteworthy that the October 2008 Nerve Conduction Study report suggests a moderate bilateral median neuropathy at the wrist, the right worse than the left. Consequently, the neurologist estimated the Veteran's median nerve neuropathy and nerve dysfunction in the left hand to be moderate in nature and the Board agrees. Accordingly, for the entire appeal period, the Veteran is entitled to an increased rating of 20 percent for sensory neuropathy of the median nerve under DC 8515. However, as the manifestations are not greater, and as the medical evidence indicated that the disability was at its worst moderate, a rating in excess of 20 percent is not warranted. The Veteran's competent, credible and probative reports of numbness, weakness and tingling were considered in finding a 20 percent rating is warranted. However, the evidence as a whole does not show that the criteria for a higher evaluation are met or approximated. For these reasons, the Board finds that the Veteran does not meet or nearly approximate the criteria for a rating in excess of 20 percent for his service-connected carpal tunnel syndrome of the left hand for any period of time since the effective date of service connection. There has been no indication that the disability has caused limitation of motion of the joints of the wrist or hand. Consequently, analysis of such criteria would not lead to a higher rating. The potential application of 38 C.F.R. § 3.321(b) (1) has been considered. See Thun v. Peake, 22 Vet. App. 111 (2008). However, there has been no showing that the service-connected carpal tunnel syndrome has caused marked interference with employment, has necessitated frequent periods of hospitalization, or has otherwise rendered impractical the application of the regular scheduler standards. There is no doubt that the Veteran has impairment of nerve function. However, the regular schedular criteria contemplate the symptomatology shown in this case. Thun v. Peake, 22 Vet. App. 111 (2008). In essence, the evidence does not demonstrate an exceptional or unusual disability picture that renders impracticable the application of the regular rating schedule. As such, referral for consideration of an extraschedular evaluation is not warranted. See 38 C.F.R. § 3.321(b) (1); Bagwell v. Brown, 8 Vet. App. 337, 339 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). ORDER An initial 20 percent disability evaluation for left carpal tunnel syndrome is granted, subject to the law and regulations governing the payment of monetary benefits. REMAND The Veteran was most recently afforded a VA examination assessing the severity of the skin disability of the back and left long finger fracture in June 2009. In regard to his skin condition, the Veteran noted that he had itching on his back. However, he had no exudation, ulcer formation, shedding and crusting. Examination did not reveal scarring or hyperhydrosis. The skin lesions were not associated with systemic disease. Additionally, there was a linear scar located on the tip of the left long finger. The entire scar measured 0.8 cm by 0.1 cm; the scar was not painful on examination. There was no skin breakdown. This was a superficial scar with no underlying tissue damage. No inflammation, edema or keloid was noted. The scar did not limit function. In regards to his left long finger fracture, the Veteran stated that the condition did not cause pain, has never been infected and he was not receiving any treatment for it. The Veteran stated that he did not experience any functional impairment because of it. The diagnosis following examination was status post compound fracture of the left long finger, distally. The objective factors were a small scar on the distal left long finger, and it was noted that the tip of finger was hypersensitive. In this regard, the Board notes that it has been more than four years since the June 2009 VA examination evaluating the severity of the service-connected skin of the back and left long finger fracture. The mere passage of time, alone, is insufficient to require a new VA examination. See Palczewski v. Nicholson, 21 Vet. App. 174 (2007). However, the Court has held that where a claimant asserts that a disability is worse than when last rated or examined, and the available evidence is too old to adequately determine the current state of the disability, VA must provide a new examination. Olsen v. Principi, 3 Vet. App. 480, 482 (1992), citing Proscelle v. Derwinski, 2 Vet. App. 629, 632 (1992). See, too, Caffrey v. Brown, 6 Vet. App. 377, 381 (1994) (the Board should have ordered a contemporaneous examination of the Veteran because a 23-month old examination was too remote in time to adequately support the decision in an appeal for an increased rating); Allday v. Brown, 7 Vet. App. 517, 526 (1995) (where the record does not adequately reveal the current state of the claimant's disability, fulfillment of the statutory duty to assist requires a contemporaneous medical examination, particularly if there is no additional medical evidence adequately addressing the level of impairment of the disability since the previous examination); see also Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); Green v. Derwinski, 1 Vet. App. 121 (1991); and VAOPGCPREC 11-95 (April 7, 1995). At his hearing in September 2013, the Veteran maintained that his finger disability had worsened since the last examination in June 2009. The Veteran indicated that he has a scar on the tip of that finger that is now painful and tender; he also reported that he had difficulty bending that finger. With respect to the skin problem, the Veteran maintained that this condition had also worsened. The Veteran indicated that the condition is manifested by bumps on his back that bleed. The Veteran related that he no longer participates in certain activities because of the embarrassment caused by his skin condition. The Veteran reported lying on the carpet in order to scratch his back. He argued that it is clear that his condition has gotten worse and should be reevaluated. It was requested that the Veteran be afforded another VA examination in order to properly evaluate the skin condition. (Despite the need for new examinations, it should be pointed out that the Veteran said that he will be out of the country from January through September 2014.) In light of the discussion above, and to ensure full compliance with due process requirements, the case is hereby REMANDED to the agency of original jurisdiction (AOJ) for the following actions: 1. The Veteran should be asked to provide the names and addresses of any VA or non-VA care providers from which the Veteran received treatment for his skin or left long finger disability. After obtaining the necessary authorizations, the AOJ should attempt to obtain copies of the treatment records. If the AOJ is unsuccessful in its efforts to obtain any such evidence, it should so inform the Veteran of its inability to obtain the evidence and request the Veteran to submit such evidence. 2. The Veteran should also be scheduled for a VA dermatology examination to determine the current severity of the skin disability of his back. The claims folder must be made available to the examiner for review prior to the examination. All indicated tests and studies should be performed, and the examiner should review the results of any testing prior to completing the report. The examination report should include discussion of the Veteran's documented medical history and assertions. In addition, the examiner should: (a) describe in detail all symptoms reasonably attributable to service-connected skin condition and its current severity. The examiner should describe the areas of the body affected by the skin condition, to include the percentage of the entire body affected by the service-connected condition and the percentage of exposed areas affected. (b) describe any therapy that the Veteran has undergone since 2009, if any, and what medications he currently uses. It should be specifically noted whether the Veteran has required systemic therapy such as corticosteroids or other immunosuppressive drugs for control of the skin condition. If the Veteran requires systemic therapy such as corticosteroids or other immunosuppressive drugs, the examiner should note the frequency and duration of such use. As was noted above, in light of the Veteran's absence from the United States until September 2014, all reasonable accommodations should be made to enable completion of the development sought. If the development sought cannot be completed, the AOJ should provide for the record an explanation of the efforts that were made and why no further accommodation is feasible. 3. Schedule the veteran for a VA examination to ascertain the severity of his service-connected left long finger fracture residuals. The claims folder and a copy of this remand must be made available to the examiner for review in connection with the examination. Any indicated evaluations, studies, and tests should be conducted. The examination must include range of motion studies for the left long finger. The examiner should specifically state whether it is at least as likely as not that the Veteran has any additional loss of motion of the left long finger due to pain or flare-ups of pain, supported by objective findings, and whether there is any such additional limitation of motion of the left long finger due to weakened movement, excess fatigability, incoordination, or flare-ups of such symptoms or any other signs or symptoms. Any additional limitation of motion should be expressed in degrees. The left long finger scar should be described in detail. As was noted above, in light of the Veteran's absence from the United States until September 2014, all reasonable accommodations should be made to enable completion of the development sought. If the development sought cannot be completed, the AOJ should provide for the record an explanation of the efforts that were made and why no further accommodation is feasible. 4. Thereafter, the AOJ should review the claims folder and ensure that all of the requested development actions have been conducted. If any development is incomplete, appropriate corrective action is to be taken. Specific attention is directed to the examination reports. If a requested examination does not include fully detailed descriptions of symptoms and necessary information, or adequate responses to the specific information requested, the report must be returned for corrective action. 38 C.F.R. § 4.2 (2013); see also Stegall v. West, 11 Vet. App. 268 (1998). 5. Thereafter, the AOJ should re-adjudicate the Veteran's claims on the basis of all evidence of record and all applicable laws and regulations. If a benefit sought is not granted, the Veteran and his representative should be furnished a Supplemental Statement of the Case (SSOC). Thereafter, the Veteran and his representative should be given the opportunity to respond before the case is returned to the Board. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This case must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board 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. 2013). ________________________________ MARK F. HALSEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs