Citation Nr: 1615921 Decision Date: 04/20/16 Archive Date: 04/26/16 DOCKET NO. 13-25 594 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Philadelphia, Pennsylvania THE ISSUES 1. Entitlement to a disability rating in excess of 30 percent for service-connected posttraumatic stress disorder (PTSD) with alcohol dependence. 2. Entitlement to a compensable disability rating for service-connected tinea pedis. 3. Entitlement to a total disability rating based upon individual unemployability (TDIU). REPRESENTATION Appellant represented by: New Jersey Department of Military and Veterans' Affairs ATTORNEY FOR THE BOARD Stuart Sparker, Associate Counsel INTRODUCTION The Veteran served on active duty from December 1968 to December 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from April 2011, December 2011, and September 2012 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Philadelphia, Pennsylvania. The issues of entitlement to a compensable disability rating for service-connected tinea pedis and a TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDING OF FACT The Veteran's service-connected PTSD is manifested by occupational and social impairment, with deficiencies in most areas, including family relations, judgment, thinking, and mood. CONCLUSION OF LAW The criteria for a 70 percent rating for PTSD are satisfied. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.321, 4.3, 4.7, 4.130, Diagnostic Code (DC) 9411 (2015). REASONS AND BASES FOR FINDING AND CONCLUSION I. Duties to Notify and Assist VA's duties to notify and assist under the Veterans Claims Assistance Act of 2000 (VCAA) have been satisfied. See 38 U.S.C.A §§ 5103, 5103A (West 2014); 38 C.F.R. §§ 3.159, 3.326(a) (2015). Because this appeal stems from a granted service connection claim, the issue of whether there was adequate VCAA notice is moot, as the purpose of such notice was fulfilled with the grant of service connection. See Goodwin v. Peake, 22 Vet. App. 128, 137 (2008); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Concerning the duty to assist, the Veteran's service treatment records and VA treatment records have been associated with the claims file. See 38 C.F.R. § 3.159(c). He has not identified any other records or evidence he wished to submit or have VA obtain. Additionally, VA examinations were performed in September 2010, August 2012, and March 2015 that include consideration of the Veteran's medical history and set forth all pertinent findings, such that the Board is able to make a fully informed decision. See Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007); 38 C.F.R. §§ 3.159(c)(4), 3.326(a), 3.327 (2015). There is no evidence indicating that there has been a material change in the severity of the Veteran's PTSD since the last examination. See 38 C.F.R. § 3.327(a) (providing that reexaminations will be requested whenever VA needs to determine the current severity of a disability). Thus, further examination is not warranted. See Palczewski v. Nicholson, 21 Vet. App. 174 (2007) (holding that a new VA examination is not required simply because of the passage of time since an otherwise adequate examination was conducted); accord VAOPGCPREC 11-95 (April 7, 1995). Accordingly, the duty to assist is satisfied. In light of the above, the Veteran has had a meaningful opportunity to participate effectively in the processing of this claim, and no prejudicial error has been committed in discharging VA's duties to notify and assist. See Shinseki v. Sanders, 556 U.S. 396, 407, 410 (2009); Conway v. Principi, 353 F.3d 1369, 1374 (Fed. Cir. 2004); Arneson v. Shinseki, 24 Vet. App. 379, 389 (2011); Vogan v. Shinseki, 24 Vet. App. 159, 163 (2010). II. PTSD The Veteran asserts that a rating greater than 30 percent is warranted for PTSD. For the following reasons, the Board finds that entitlement to a higher rating is established. VA has adopted a Schedule for Rating Disabilities to evaluate service-connected disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. § 3.321; see generally, 38 C.F.R. § Part IV. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life, including employment. 38 C.F.R. § 4.10 (2015). The percentage ratings in the Schedule for Rating Disabilities represent, as far as practicably can be determined, the average impairment in earning capacity resulting from service-connected diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2015). Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. 38 C.F.R. § 4.7 (2015). Otherwise, the lower rating will be assigned. Id. All reasonable doubt regarding the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3; see also 38 C.F.R. § 3.102. The schedule recognizes that disability from distinct injuries or diseases may overlap. See 38 C.F.R. § 4.14 (2015). However, the evaluation of the same disability or its manifestations under various diagnoses, which is known as pyramiding, is to be avoided. Id. Because the level of disability may have varied over the course of the claim, the rating may be "staged" higher or lower for segments of time during the period under review in accordance with such variations, to the extent the evidence shows distinct time periods where the service-connected disability has exhibited signs or symptoms that would warrant different ratings under the rating criteria. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007); Fenderson v. West, 12 Vet. App. 119, 126 (1999). The Board has an obligation to provide an adequate statement of reasons or bases supporting its decision. See 38 U.S.C.A. § 7104(d)(1) (West 2014); Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Allday v. Brown, 7 Vet. App. 517, 527 (1995). The Board must assess the credibility and weight of the evidence, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Caluza v. Brown, 7 Vet. App. 498, 506 (1995). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence on any issue material to the claim. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102 (providing, in pertinent part, that reasonable doubt will be resolved in favor of the claimant). When the evidence supports the claim or is in relative equipoise, the claim will be granted. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); see also Wise v. Shinseki, 26 Vet. App. 517, 532 (2014). If the preponderance of the evidence weighs against the claim, it must be denied. See id.; Alemany v. Brown, 9 Vet. App. 518, 519 (1996). The Veteran's PTSD has been rated under 38 C.F.R. § 4.130, Diagnostic Code (DC) 9411. Under the Rating Formula, A 30 percent disability rating requires: 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, mild memory loss (such as forgetting names, directions, or recent events). A 50 percent disability rating requires: 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 complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent disability rating requires: 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 worklike setting); inability to establish and maintain effective relationships. A 100 percent disability rating requires: 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. The symptoms associated with each evaluation under the General Rating Formula do not constitute an exhaustive list, but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Thus, the evidence considered in determining the appropriate evaluation of a psychiatric disorder is not restricted to the symptoms set forth in the General Rating Formula. See id. Rather, VA must consider all symptoms of a claimant's condition that affect his or her occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association's DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS (4th ed. 1994) (DSM-IV). Id. at 443. (The DSM-IV has been recently updated with a Fifth Edition (DSM-5), and VA has issued an interim final rule amending certain provisions in the regulations to reflect this update, including the Schedule for Rating Disabilities. 79 Fed. Reg. 45093. The amendments only apply to applications that are received by VA or are pending before the agency of original jurisdiction on or after August 4, 2014; they do not apply to appeals already certified to the Board or pending before the Board. Id.) If the evidence demonstrates that the claimant's psychiatric disorder produces symptoms and resulting occupational and social impairment equivalent to that set forth in the criteria for a given rating in the General Rating Formula, then the appropriate, equivalent rating will be assigned. Mauerhan, 16 Vet. App. at 443. In this regard, the Board must consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126 (2015); Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013) (noting that the 'frequency, severity, and duration' of a veteran's symptoms 'play an important role' in determining the disability level). The severity of the symptoms and the degree of occupational and social impairment they cause are independent factors; both must be satisfied to assign a given rating under the Rating Formula. See Vazquez-Claudio, 713 F.3d at 116 (rejecting an interpretation of § 4.130 that would allow 'a veteran whose symptoms correspond[ed] exactly to a 30 percent rating' to be granted a 70-percent rating solely because they affected most areas). In other words, there are two elements that must be met to assign a particular rating under the Rating Formula: (1) symptoms equivalent in severity, frequency, and duration to the symptoms corresponding to a given rating, and (2) a level of occupational and social impairment corresponding to that rating that results from those symptoms. See id. at 118 (holding that, in determining whether a 70 percent rating is warranted, VA must make 'an initial assessment of the symptoms displayed by the veteran, and if they are of the kind enumerated in the regulation, an assessment of whether those symptoms result in occupational and social impairment with deficiencies in most areas') (emphasis added). In evaluating psychiatric disorders, VA also considers a claimant's Global Assessment Functioning (GAF) scores, which are based on a scale set forth in the DSM-IV 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); DSM-IV. According to DSM-IV, a score of 61-70 indicates "[s]ome mild symptoms (e.g., depressed mood and mild insomnia OR some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships." A score of 51-60 indicates "[m]oderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) OR moderate difficulty in social, occupational, or school functioning, (e.g., few friends, conflicts with peers or co-workers)." Id. A score of 41-50 indicates "[s]erious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) OR any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job)." Id. A score of 31-40 indicates "[s]ome impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) OR major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work)." Id. A GAF score thus may demonstrate a specific level of impairment. See Richard, 8 Vet. App. at 267; Bowling v. Principi, 15 Vet. App. 1, 14-15 (2001) (both observing that a GAF score of 50 indicates serious impairment). While an examiner's classification of the level of psychiatric impairment reflected in the GAF score assigned can be probative evidence of the degree of disability, such a score is by no means determinative of the rating assigned by VA in evaluating a psychiatric disorder under the rating criteria. See 38 C.F.R. §§ 4.2, 4.126 (2015); VAOPGCPREC 10-95 (March 31, 1995). Rather, VA must take into account all of the Veteran's symptoms and resulting functional impairment as shown by the evidence of record in assigning the appropriate rating, and will not rely solely on the examiner's assessment of the level of disability at the time of examination. See 38 C.F.R. § 4.126. On VA examination in September 2010, the Veteran reported that he was getting divorced from his fifth wife and only had a close relationship with one of his five children. He stated that he was a loner with three to four friends that he did not see very often. His affect was constricted and his mood anxious. He could not do serial 7s. He had suicidal ideation and ruminations. He only slept for four hours each night. He was not employed and had been fired from his job as a bus driver because of a back disability. The examiner diagnosed PTSD, moderate, chronic, and assigned a GAF score of 60, with a prognosis that was guarded, fair. The examiner also noted that there were no remissions with capacity for adjustment. The examiner concluded that the Veteran's PTSD did not result in total occupational and social impairment, but that it did result in deficiencies in the following areas: judgment, which was fair; thinking, manifested by ruminations; family relations, in that the Veteran was divorcing for the fifth time and did not have a close relationship with his children; and mood, manifested by anxiety and depression. In an October 2011 statement, the Veteran reported, "[i]n my quest to not be alone, I have been married [] five times. Each marriage resulted into a struggle of despair, depression and sometimes mood swings which would lead to arguments of domestic disputes without warrant on my part." He further reported, "I found myself constantly depressed over the loss of my bothers where I am angry and disoriented throughout the course of a period of two out of three days per week. I cannot watch war movies or communicate about my entire ordeal with my fiancé without nightmares. My reactions lead to depression and argumentative behavior with my fiancé. Although she understands, it is a constant anxiety for me." In an August 2012 VA examination, the examiner noted the Veteran's depressed mood, anxiety, panic attacks weekly or less often, and chronic sleep impairment. However, the examiner also noted the Veteran was currently in his sixth marriage and had four biological children but was only close with one of them. The examiner noted that the Veteran did not know where his other three children were at the time of the examination. Regarding friendships, the Veteran reported that he had one close friend and they were like brothers until his friend starting doing drugs and their relationship deteriorated. The examiner also noted the Veteran was fired from his job as a bus driver in 2010. The Veteran reported that he collected unemployment until he was able to collect his social security benefits at the age of 62. He was also being treated by a VA psychologist and was prescribed Zoloft and trazodone for PTSD. He continued to be dependent on alcohol and his assigned GAF score was 60, indicating moderate PTSD. The Veteran's spouse reported in her September 2012 statement that Veteran was consuming more than three beers a day and was constantly in a daze. She further reported that when the Veteran goes to sleep, he tosses, turns, yells, moans loudly, and fights in his sleep. In a March 2015 VA examination, the examiner diagnosed the Veteran with moderate PTSD with secondary alcohol dependence. The examiner noted the Veteran's PTSD symptoms included depressed mood, anxiety, panic attacks more than once a week, chronic sleep impairment, and disturbances of motivation and mood. Once again, the examiner noted the Veteran was married to his sixth wife at the time of the examination and had four biological and two stepchildren. The examiner noted that the Veteran had a close relationship with his wife and his stepchildren. The Veteran reported starting a friendship with another Veteran that lasted six months but ended when, "he turned on me." The examiner also noted the Veteran had been isolating himself since. Occupationally, the Veteran reported last working in 2010, employed as a bus driver. The examiner further noted that the Veteran's PTSD symptoms caused clinically significant distress or impairment in social, occupational, or other important areas of functioning. The Veteran denied any suicidal or homicidal thoughts or plans. The foregoing medical evidence warrants a 70 percent rating for the Veteran's PTSD. On examination in September 2010, he was shown to have deficiencies in most areas, including family relations, judgment, thinking, and mood. With respect to the duration and frequency of the Veteran's symptoms, the examiner indicated that there were no remissions. The evidence demonstrates an inability to establish and maintain effective relationships and unprovoked irritability. The Veteran is currently married to his sixth wife and stated in his October 2011 statement that each prior marriage was lead into despair, depression and sometimes mood swings leading to arguments of domestic disputes as a result of his PTSD symptoms. The Veteran has also been unable to maintain relationships with his children, reporting that he does not know where his four biological children are, let alone maintain an effective relationship with them. Resolving any doubt in favor of the claim, the Veteran's PTSD symptoms more nearly approximates the criteria for a 70 percent rating. See 38 C.F.R. § 4.130, DC 9411; 38 U.S.C.A. § 5107; 38 C.F.R. §§ 3.102, 4.3. However, the preponderance of the evidence weighs against assignment of a 100 percent rating for the Veteran's service-connected PTSD. The Veteran's symptoms are not equivalent in severity to the symptoms associated with a 100 percent rating under the General Rating Formula. He does not have any of the symptomatology listed for that rating. Rather, his symptoms more closely approximate the symptoms corresponding to a 70 percent rating or less under the General Rating Formula. See 38 C.F.R. § 4.130. The fact that they are readily captured by the criteria for a 70 percent rating or below indicates that they are not equivalent in severity to the symptoms associated with a 100 percent rating, which necessarily requires more severe symptoms. In any event, the evidence does not otherwise support a finding of equivalency. Because his symptoms are not equivalent in severity to a 100 percent rating, consideration of their frequency or duration is moot. See Mauerhan, 16 Vet. App. at 443; Vazquez-Claudio, 713 F.3d at 117. Moreover, and in the alternative, the Veteran's symptoms do not produce total occupational and social impairment. He maintains a relationship with his wife, one of his children, and some friends. Accordingly, the Veteran's symptoms do not produce the level of occupational and social impairment required for a 100 percent rating. See 38 C.F.R. § 4.130, General Rating Formula. Because the Veteran's symptoms are not the same or equivalent in severity to the symptomology corresponding to a 100 percent rating, and do not result in total occupational and social impairment, the criteria for a 100 percent rating are not more nearly approximated. See 38 C.F.R. § 4.130, DC 9435; Vazquez-Claudio, 713 F.3d at 116, 188. Rather, the preponderance of the evidence shows that the Veteran's PTSD more nearly approximates the criteria for a 70 percent rating under DC 9411 and the General Rating Formula. See 38 C.F.R. § 4.130. The evidence shows that the Veteran's PTSD has not met or approximated the criteria for a rating greater than 70 percent at any point during the pendency of this claim, for the reasons explained above. Rather, it has more nearly approximated the criteria for a 70 percent rating throughout this period. Thus, staged ratings are not appropriate for the time period under review. See Fenderson, 12 Vet. App. at 126. Referral of the Veteran's PTSD for extraschedular consideration is not warranted. See 38 C.F.R. § 3.321(b); Thun v. Peake, 22 Vet. App. 111, 114 (2008). A comparison of his symptoms and resulting functional impairment with the schedular criteria does not show 'such an exceptional or unusual disability picture . . . as to render impractical the application of the regular schedular standards.' 38 C.F.R. § 3.321(b). In this regard, as explained above, the Veteran's symptoms as well as their effects on occupational and social functioning and general level of severity are contemplated by the General Rating Formula, which takes into account these and similar symptoms and the degree of occupational and social impairment they cause. See 38 C.F.R. § 4.130, DC 9411, General Rating Formula. Although a given symptom may not be specifically mentioned in the General Rating Formula, the symptoms set forth therein are not meant to constitute an exhaustive list but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. See Mauerhan, 16 Vet. App. at 442. Thus, the fact that a given symptom is not mentioned in the rating criteria is not in itself a basis for extraschedular referral absent evidence that it produces disability distinct from, or more severe than, the levels of disability contemplated by the schedular criteria such as to render their application impractical. Here, the evidence shows that the Veteran does not have signs, symptoms, or functional impairment resulting in disability distinct from, or more severe than, the disability picture contemplated by a 70 percent rating under the General Rating Formula, such as to render application of the regular schedular standards impractical. The degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life, including employment. 38 C.F.R. § 4.10. Thus, the schedular criteria are generally assumed to adequately account for an individual's circumstances, even if they do not specifically address such circumstances or challenges unique to the claimant. See id.; 38 C.F.R. § 4.1; cf. VAOPGCPREC 6-96 (August 16, 1996) (holding that the fact that circumstances specific to a claimant may cause the effects of a service-connected disability to be more profound in that claimant's case does in itself provide a basis for extraschedular referral). In short, there is no indication that the Veteran's symptoms and clinical findings are so exceptional or unusual in relation to the schedular criteria such as to render application of the rating schedule impractical. Accordingly, as the first Thun factor is not satisfied, consideration of the other Thun factors is moot, and the Board will not refer the case for extraschedular consideration. See 38 C.F.R. § 3.321(b); Thun, 22 Vet. App. at 114. ORDER Entitlement to an initial disability rating of 70 percent for PTSD is granted, subject to the law governing payment of monetary benefits. REMAND Unfortunately, a remand is also required in this case. Although the Board sincerely regrets the additional delay, it is necessary to ensure that there is a complete record upon which to decide the Veteran's claims so that he is afforded every possible consideration. With respect to the claim for an increased rating for tinea pedis, the October 2011 and March 2015 VA examination reports show that the Veteran uses cream, or topical medications, to treat his tinea pedis. However, a VA treatment record dated in February 2015 shows that he was prescribed oral Terbinafine, although he apparently was not able to tolerate this medication. In light of this, remand for an additional VA examination is required. The issue of TDIU has been reasonably raised by the record. A claim for TDIU is considered part and parcel of an increased rating claim. See Rice v. Shinseki, 22 Vet. App. 447, 453 (2009). The Veteran has not worked since 2010. Prior to 2010, the Veteran was a bus driver. However, the Veteran has a history of alcohol abuse as secondary to his service-connected PTSD, effectively limiting his ability to work in that field. Additionally, the March 2015 VA examiner noted that the Veteran's tinea pedis condition impacted his ability to work because the condition forces the Veteran to take 15-30 minutes to stand up and he was only able stand for 15 minutes at a time there after. The examiner also noted that the Veteran was only able to walk for 10 minutes before needing to rest and was constantly irritable. Accordingly, the case is REMANDED for the following action: 1. Send the Veteran a VCAA letter concerning the issue of entitlement to a total disability rating based on individual unemployability. He should also be provided with and asked to complete and return a VA Form 21-8940. 2. Make arrangements to obtain the Veteran's complete VA treatment records, dated since November 2015. 3. Thereafter, schedule the Veteran for an appropriate VA examination to determine the severity of his service-connected tinea pedis. The claims file, to include a copy of this remand, must be made available to the VA examiner, who must note its review. If possible, the examination should be conducted during an exacerbation or active phase of the Veteran's tinea pedis in order to accurately determine the current severity of his skin condition. Efforts to schedule the Veteran for an examination during an active period of his tinea pedis must be documented, and the documentation must be associated with the claims file. The examiner should use the appropriate Disability Benefits Questionnaire (DBQ) to assess the severity of the Veteran's service-connected tinea pedis. In particular, the examiner should carefully review the Veteran's records and state whether systemic therapy such as corticosteroids or other immunosuppressive drugs are required for the treatment of the Veteran's tinea pedis, and if so, for what duration. In so doing, the examiner must address the VA treatment notes dated in February 2015 showing that the Veteran was prescribed oral Terbinafine (regardless of whether or not he was able to tolerate this medication). All examination findings, along with the complete rationale for all opinions expressed, must be set forth in the examination report. 4. Schedule the Veteran for an appropriate VA examination, to be conducted, if possible, by a vocational rehabilitation specialist, to evaluate the issue of entitlement to a TDIU. All indicated tests and studies are to be performed, and a comprehensive social, educational and occupational history obtained. In conjunction with the examination, the claims folder must be made available to and reviewed by the examiner. Following evaluation of the Veteran, the examiner should identify all limitations imposed on the Veteran as a consequence of his service-connected PTSD and tinea pedis and opine as to the impact of the service-connected disabilities, to include in the aggregate, on his ability to secure and follow a substantially gainful occupation. If it is the examiner's opinion that the Veteran's service-connected disabilities do not render her unemployable, the examiner must suggest the type or types of employment in which the Veteran would be capable of engaging with his service-connected disabilities, given his skill set and educational background. All examination findings, along with the complete rationale for all opinions expressed, must be set forth in the examination report. 5. Finally, readjudicate the claims on appeal. If the benefits sought on appeal remain denied, the Veteran and his representative should be provided a supplemental statement of the case (SSOC). A reasonable period of time should be allowed for response before the appeal is returned to the Board. 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 2014). ______________________________________________ P. M. DILORENZO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs