Citation Nr: 1702371 Decision Date: 01/27/17 Archive Date: 02/09/17 DOCKET NO. 10-49 134 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUES 1. Entitlement to an increased disability rating for posttraumatic stress disorder (PTSD), panic disorder, and major depressive disorder (MDD), with alcohol abuse in remission and marijuana dependence, evaluated as 50 percent disabling, prior to March 23, 2016, and 70 percent disabling from March 23, 2016. 2. Entitlement to a compensable disability rating for bilateral hearing loss disability. 3. Entitlement to an initial rating in excess of 10 percent for sprain, left knee status-post surgery with scars. 4. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Christopher Loiacono, Agent WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD Joseph R. Keselyak, Counsel INTRODUCTION The Veteran served on active duty between August 1966 and April 1970, and October 1975 and March 1976. This matter comes before the Board of Veterans' Appeals (Board) on appeal from December 2009 and November 2010 rating decisions of the Muskogee, Oklahoma Department of Veterans Affairs (VA) Regional Office (RO). In June 2015, the Veteran testified in support of his claims before the undersigned Veterans Law Judge at a videoconference hearing convened at the RO. A transcript of the hearing has been included in the record. In October 2015, the Board remanded the matters for further development. In an April 2016 rating decision and associated May 2016 Supplemental Statement of the Case (SSOC), the RO increased the evaluation of the service-connected psychiatric disabilities to 70 percent, effective March 23, 2016, the date of a VA examination obtained pursuant to the Board's remand in June 2015. See Hart v. Mansfield, 21 Vet. App. 505 (2007) (holding that 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). Because the maximum benefit was not granted, the issue of entitlement to a higher evaluation remains on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). With respect to the RO's issuance of the April 2016 rating decision and May 2016 SSOC, the Board notes that in June 2016, the Veteran's agent filed a formal Notice of Disagreement (NOD) (VA Form 21-0958), with respect to the April 2016 rating decision. He also filed a formal Appeal to the Board of Veterans' Appeals (VA Form 9, i.e. Substantive Appeal) in June 2016 in response to the May 2016 SSOC. In this regard the Board notes that the matter is currently before the Board, and the NOD and Substantive Appeal are unnecessary. The April 2016 rating decision was administratively issued to reflect the staged rating effectuated by the RO in the SSOC. Here, the Board notes the Veteran has been characterized as having symptoms of secondary cannabis abuse. See March 2016 VA examination report. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active duty but no compensation will be paid if the disability is a result of abuse of alcohol or drugs. 38 U.S.C.A. §§ 105, 1110 (West 2014); 38 C.F.R. §§ 3.301, 3.303 (2016). However, the law does not preclude a veteran from receiving compensation for an alcohol or drug abuse disability acquired as secondary to, or as a symptom of, a veteran's service-connected disability. Allen v. Principi, 237 F.3d 1368 (Fed. Cir. 2001). In Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009), the United States Court of Appeals for Veterans Claims (Court) held that, in determining the scope of a claim, the Board must consider the claimant's description of the claim; symptoms described; and the information submitted or developed in support of the claim. In light of the Court's decision in Clemons, the Board has recharacterized the issue of entitlement to a higher disability evaluation for psychiatric disability on appeal to address this assessment. The issues of entitlement to an initial rating in excess of 10 percent for sprain, left knee status-post surgery with scars, and entitlement to a TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. Prior to March 23, 2016, PTSD, panic disorder, and MDD, with alcohol abuse in remission and marijuana dependence manifested by sleep impairment, near-continuous depression and anxiety, isolation, hypervigilance, intermittent suicidal ideation, unprovoked irritability and anger, difficulty in adapting to stressful circumstances, and difficulty in establishing and maintaining effective social and work relationships. 2. At no point during the applicable period has PTSD, panic disorder, and MDD, with alcohol abuse in remission and marijuana dependence resulted in total occupational and social impairment as the result of symptoms such 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. 3. Throughout the applicable period, the Veteran has had hearing loss in the right ear with a Numeric Designation of II and hearing loss in the left ear with a Numeric Designation of II, at worst. CONCLUSIONS OF LAW 1. Prior to March 23, 2016, the criteria for the assignment of a 70 percent disability evaluation for PTSD, panic disorder, and MDD, with alcohol abuse in remission and marijuana dependence, have been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411 (2015). 2. The criteria for the assignment of a disability evaluation in excess of 70 percent for PTSD, panic disorder, and MDD, with alcohol abuse in remission and marijuana dependence, are not met or approximated. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411 (2015). 3. The criteria for a compensable evaluation for bilateral hearing loss disability have not been met or approximated. 38 U.S.C.A. §§ 1155 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.385, 4.1, 4.7, 4.85 Diagnostic Code 6100, Tables VI, VIa, VII, 4.86 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Notice and Assistance Upon receipt of a complete or substantially complete application for benefits and prior to an initial unfavorable decision on a claim by an agency of original jurisdiction, VA is required to notify the appellant of the information and evidence not of record that is necessary to substantiate the claim. In the notice, VA will inform the claimant which information and evidence, if any, that the claimant is to provide to VA and which information and evidence, if any, that VA will attempt to obtain on behalf of the claimant. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159 (2013); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Notice should also address the rating criteria and effective date provisions that are pertinent to the appellant's claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The RO provided the appellant pre-adjudication notice by letters dated in November 2009 and September 2010. With respect to the Board hearing, the Court of Appeals for Veterans Claims held in Bryant v. Shinseki, 23 Vet. App. 488 (2010), that 38 C.F.R. 3.103(c)(2) requires that the RO official or VLJ who conducts a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, the VLJ noted the current appellate issue at the beginning of the hearing, and asked questions to clarify the Veteran's contentions and treatment history. The VLJ particularly suggested that evidence relating to severity of the conditions would assist in substantiating the claims. The VLJ elicited testimony from the Veteran regarding his symptoms and their impact on his life and employment. The Veteran demonstrated through his testimony that he had actual knowledge concerning what is required to substantiate his claims. Neither the Veteran nor his agent has asserted that VA failed to comply with 38 C.F.R. 3.103(c)(2), nor have they identified any prejudice in the conduct of the hearing. VA has obtained the Veteran's service treatment records, VA and Social Security Administration (SSA) records, assisted the Veteran in obtaining evidence, afforded the Veteran physical examinations, obtained medical opinions as to the severity of the disabilities addressed herein, and afforded the Veteran the opportunity to give testimony before the Board. All known and available records relevant to the issues on appeal have been obtained and associated with the Veteran's claims file; and the Veteran has not contended otherwise. The United States Court of Appeals for Veterans Claims (hereinafter "the Court") has held that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the VA examinations obtained in this case are adequate. They are predicated on a substantial review of the record and medical findings and consider the Veteran's reports, symptoms and history. As the examination reports ultimately provide sufficient information such that the Board can render an informed determination, they are adequate. Accordingly, VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issues addressed in this decision has been met. 38 C.F.R. § 3.159(c)(4). VA has substantially complied with the notice and assistance requirements and the Veteran is not prejudiced by a decision on the claim at this time. Analysis Disability evaluations are determined by the application of a schedule of ratings, which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. Each disability must be viewed in relation to its history, with an emphasis on the limitation of activity imposed by the disabling condition. Medical reports must be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the veteran working or seeking work. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. See 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 4.1, 4.2, 4.7 (2015). While the Veteran's entire history is reviewed when assigning a disability evaluation, 38 C.F.R. § 4.1, where service connection has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). The Court has held that in determining the present level of a disability for any increased evaluation claim, the Board must consider the application of staged ratings. See Fenderson v. West, 12 Vet. App. 119 (1999); see also Hart, supra.. In other words, where the evidence contains 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 would be appropriate. Therefore, the Board will determine whether further staged evaluations are warranted. Psychiatric Disability Evaluation When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. The rating agency shall assign a rating based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign a rating solely on the basis of social impairment. See 38 C.F.R. § 4.126 (2015). The Veteran's PTSD is currently rated under 38 C.F.R. § 4.130, Diagnostic Code (DC) 9411. A 50 percent rating is assigned when there is 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. Id. A 70 percent rating is warranted when there is occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking, or mood due to symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; 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 work-like setting); and an inability to establish and maintain effective relationships. Id. A 100 percent evaluation is warranted where there is evidence of total occupational and social impairment due to 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; disorientation to time or place; memory loss for names of close relatives, own occupation or own name. Id. The "such symptoms as" language of the diagnostic codes for mental disorders in 38 C.F.R. § 4.130 means 'for example' and does not represent an exhaustive list of symptoms that must be found before granting the rating of that category. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). However, as the Court also pointed out in that case, "[w]ithout those examples, differentiating a 30% evaluation from a 50% evaluation would be extremely ambiguous." Id. The Court went on to state that the list of examples "provides guidance as to the severity of symptoms contemplated for each rating." Id. Accordingly, while each of the examples needs not be proven in any one case, the particular symptoms must be analyzed in light of those given examples. Put another way, the severity represented by those examples may not be ignored. The Federal Circuit has indicated that when addressing the issue of a veteran's entitlement to a disability rating under 38 C.F.R. § 4.130, an explicit finding as to how most of the enumerated areas are affected may be important, if not absolutely required. See Vazquez-Claudio v. Shinseki, 2012-7114 (Fed. Cir. Apr. 8, 2013). Global Assessment of Functioning (GAF) scores are a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." See Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing the American Psychiatric Association 's DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS, Fourth Edition (DSM- IV), p. 32). A GAF score of 41-50 illustrates "[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)." A score of 51-60 represents "[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). A score of 61-70 illustrates "[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." Id. An examiner's classification of the level of psychiatric impairment at the moment of examination, by words or by a GAF score, is to be considered, but it is not determinative of the percentage VA disability rating to be assigned; the percentage evaluation is to be based on all the evidence that bears on occupational and social impairment. See 38 C.F.R. § 4.126 (2015); VAOPGCPREC 10-95 (Mar. 1995); 60 Fed. Reg. 43186 (1995). The Board notes that the GAF Scale has been abandoned in the updated fifth edition of the DSM (DSM-5). In this case, however, the DSM-IV was in use at the time most of the medical entries of record were made. Thus, the GAF scores assigned remain relevant for consideration in this appeal. In this case, the Veteran essentially contends that his PTSD is more disabling than contemplated by the current disability evaluations. The Veteran last worked a truck driver in March 2009, and was apparently laid-off due to economic reasons. See September 2011 VA Form 21-4192 (Request for Employment Information in Connection with Claim for Disability Benefits). The Veteran was afforded a VA psychiatric evaluation examination in July 2009. Examination resulted in assessment of PTSD, as well as panic disorder, major depressive disorder (MDD) and alcohol abuse in remission since 2007. In terms of symptoms, those attributed to PTSD included nightmares, intrusive thoughts, and flashbacks. Panic disorder manifested with heart racing, dizziness, not having enough air, and the feeling he was dying. MDD resulted in a having depressed mood, generalized loss of interest, low libido, no appetite, insomnia, and low energy. A GAF score of 53 was assigned, Mental status examination (MSE) in July 2009 reflected that the Veteran was a reliable historian. Orientation was within normal limits. Appearance and hygiene were appropriate. Behavior was appropriate. The Veteran maintained good eye contact during the exam. Affect and mood showed a disturbance of motivation and mood. He rarely had the motivation to work on projects around his home. Communication was within normal limits. Speech was within normal limits. Concentration was within normal limits. Panic attacks occurred less than once per week, or about twice per month, marked with heart racing, not having enough air, the feeling as if he is dying, and dizziness. There was no suspiciousness present. There was no report of a history of delusions. At the time of examination, there was no delusion observed. There was no report of a history of hallucinations. No hallucination was observed. Obsessional rituals were absent. Thought processes were appropriate. The Veteran was able read and understand directions. He did not have slowness of thought nor confusion. Judgment was not impaired. Abstract thinking was normal. Memory was within normal limits. Suicidal ideation was absent. Homicidal ideation was absent. In closing, the July 2009 VA examiner remarked that the Veteran was mentally capable of managing benefit payments in his own best interest, and his own checking/banking affairs. Mentally, he occasionally had some interference in performing activities of daily living because he preferred to stay in his home. The examiner stated that the best description of the Veteran's psychiatric impairment was "psychiatric symptoms cause occupational and social impairment with reduced reliability and productivity." In this regard, the examiner cited to the following symptoms: panic attacks more than once a week, disturbances of motivation and mood and difficulty in establishing and maintaining effective work and social relationships." The examiner found no difficulty in understanding commands. The Veteran did not appear to be any threat of danger or injury to self or others. A May 2010 MSE in the SSA records from Dr. Ball, reflects assessment of PTSD, severe, with a GAF of 49. At the time, the Veteran was appropriately dressed, and cooperative. He had no extraneous movements, and denied drug and alcohol problems. He was alert and oriented times 3. There was no indication of thought disorder. He related that he quit working secondary to COPD. In terms of PTSD he described night terrors, and sleep impairment, averaging 2 hours per night. He described hypervigilance in checking the grounds of his house. In a normal day, he tended to stay to himself and worked in his shop and watched TV. He had 2 close friends, and was married. Short and long term memory were adequate. He could do simple arithmetic in his head, and could understand idioms. SSA records dated in August 2010 contain a Mental Residual Functional Capacity Assessment. The assessment reflects moderate limitation the ability to understand, remember and carry out detailed instructions. It also documents marked limitation of the ability to interact appropriately with the general public. The Veteran was documented to be able to perform simple and some complex tasks with supervision, and could relate to others on a superficial work basis. He was to avoid contact with the general public due to PTSD, but could adapt to a work situation. PTSD, severe, with a GAF of 49 was assessed. A November 2010 VA mental health initial consultation note reflects referral for symptoms of PTSD, anger, and suicidal and homicidal ideation. The Veteran described that he was afraid that he would choke his dogs or his wife, and related that he lashed out at his children. He denied any physical outbursts, but feared that he may do so. He endorsed depression, and that he coped with psychological distress by avoiding others. He had been married for 31 years. PTSD with a GAF score of 50 was assessed. A VA psychiatric note dated in December 2010 reflects the Veteran's reports of anger and irritability. He reported depression and on and off suicidal and homicidal ideation. He had not acted in violence, but was afraid he might do so. He described sleep impairment, and that he stayed to himself. He endorsed hypervigilance, feeling numb and cut off, and depressed. He was awake, alert and oriented, and cooperative with fair eye contact. He was appropriately dressed. Speech was normal. He was anxious and irritable. Mood was congruent. There was no mania/hypomania, flight of ideas, looseness of association, or delusion. Memory was intact. PTSD with a GAF score of 56 was assessed. Subsequent VA records document similar impressions of PTSD and GAF scores in the mid-50 range. In August 2011, the Veteran was once again examined, with PTSD assessed. In terms of occupational and social impairment, the examiner noted occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. In terms of symptoms, the examiner identified depressed mood, anxiety, chronic sleep impairment, and mild memory loss, such as forgetting names, directions or recent events. The examiner specifically found it less likely than not that PTSD would result in an inability to obtain substantially gainful employment. The examiner explained that the Veteran related a history of work conflict, particularly in the 1970s, that the Veteran related that he got along well with his colleagues and supervisors and retired due to COPD. Of record is an October 2012 psychological disability examination report from Dr. Rubin. In terms of education and employment, Dr. Rubin noted that the Veteran had a GED and had last worked as a truck driver in 2009, at which time he was laid off due to economic reasons. Dr. Rubin noted that the Veteran had remained out of work since then due to disability. At the time of the examination, the Veteran reported significant emotional distress, and presented with reports of general anxiety and tension, panic attacks, insomnia, depressed moods, a loss of interest and pleasure in all the usual activities and pleasures of life as well as social withdrawal, disinterest in (and resistance to) socializing. MSE by Dr. Rubin in October 2012 showed that the Veteran's abstract thinking ability appeared intact. His level of consciousness during the session was unimpaired. Speech was comprehensible. Overall, he answered questions willingly, and to the best of his ability. His attention and concentration for the interview examination was within the normal range. His speech was of normal rate with normal volume. He spontaneously and his stream of speech was consistent with apprehension, clinically significant depression, as well as significant rumination. He was oriented to person, place and. time. There was no evidence of formal thought disorder, hallucinations, delusions or of any florid or major underlying psychopathology. Thought processes were normal. Overall, The Veteran described and manifested clinically significant anxiety and depression, with active suicidal ideations. His overall mental status was significant for blunted affect. His mood reflected significant tension, depression and with an underlying tone of depression. Dr. Rubin assessed both MDD and PTSD, and assigned a GAF score of 50, noting that the Veteran was significantly anxious. In terms of work, Dr. Rubin specifically found that the Veteran was incapable of competitive employment, given the nature of his psychiatric symptoms. Dr. Rubin explained that the Veteran's overall ability to concentrate and sustain persistence for work tasks was markedly impaired. He also found that the Veteran's ability to deal with supervisors and co-workers was moderately impaired, with his overall ability to deal with the stresses of work being moderately impaired. Dr. Rubin found the overall level of psychological disability to be "moderately impaired. However, Dr. Rubin also carried on to say that the disability is considered to be "marked." Dr. Rubin suggested that in a work environment, other than a sheltered work environment, that the Veteran's psychiatric disability would further deteriorate, preventing him from competitive employment. An October 2012 VA psychiatric note reflects reports of depressed mood, intrusive images and flashbacks related to Vietnam, avoidance of crowds, difficulty falling asleep, interrupted sleep, hypervigilance, exaggerated startle response, difficulty with concentration, irritability, and angry outbursts. He was alert and oriented to person, place, time and circumstance. His speech was normal in rate, rhythm, and tone. The Veteran's reported mood was depressed with congruent affect. His thought process was goal-directed and logical, with no evidence of loose associations. Insight and judgment were good. He reported seeing shadows "all the time," and hearing big bangs, although it was unclear whether this was related to tinnitus. There was no evidence of suicidal/homicidal thought. Subsequent VA records document similar impressions, with GAF scores in the mid-50s to 60. A December 2012 VA psychiatric note documents the Veteran's reports of an "up and down" mood, nightmares and temper problems. He reported difficulty falling and staying asleep. He reported the use of marijuana, in the absence of which he would become angry "at the drop of a hat." A GAF score of 58 was assessed, with the assessment of PTSD. Subsequent VA records document marijuana dependence. A January 2014 VA psychiatry note reflects that the Veteran reported improvement of his mood, irritability and depression. He related that his nightmares had decreased. He denied many days of depressed mood, anxiety symptoms, or anger outbursts. He tried to stay busy with routine. He denied alcohol use, but continued to use marijuana to calm down. MSE was normal, with a "fine mood." PTSD, with a GAF of 60 was assessed. In February 2014, the Veteran was afforded another VA examination. See Virtual VA records system. At this time, PTSD continued to be assessed. In terms of occupational and social impairment, the examiner specifically found occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. The Veteran attended the examination with his wife, to whom he had been married for 18 years. The Veteran related that he had worked as a welder, then a truck driver, retiring at age 60, when his COPD caused him to do so. The Veteran reported irritability and anger, but denied any history of violence or recent legal trouble. In terms of symptoms, examination disclosed depressed mood, suspiciousness, anxiety attacks, chronic sleep impairment, mild memory loss, such as forgetting names, directions or recent events, disturbances of motivation and mood. In terms of behavior, the Veteran was friendly, and seemed honest. There was no evidence of a thought disorder, and he was no threat to himself or others. He felt his medication had helped with his irritability, and he had less nightmares. He described panic attacks, with an episode 2 weeks prior to the exam, and particularly in crowded places. He went to church, and had several friends. He remained competent. A November 2014 VA social work note related to treatment of sleep disturbance and depression, reflects that the Veteran reported improvement in each symptom from a "9 to a 7." He was dressed appropriately and appeared stated age with good grooming. He had good eye contact and normal rate and volume of speech. He related well with the examiner. Mood was "down" with congruent effect of normal range and intensity. No lability was noted. The Veteran was alert and appeared fully oriented, but was not formally tested. No intellectual deficits noted. Thought processes were clear, logical, and goal-directed. Veteran denied suicidal and homicidal ideations. There were no audio/visual hallucinations, psychosis , or delusions. Insight and judgment were poor/fair. He was judged not to be a risk to himself or others. PTSD was assessed. A December 2014 VA social work note reflects that the Veteran reported feeling overwhelmed with the busy month. The Veteran struggled to build a rapport with the Licensed Clinical Social Worker (LCSW) and continued to identify his depression symptoms as permanent. He was dressed appropriately and appeared stated age with good grooming. He had good eye contact and normal rate/volume of speech, and related well with the VA examiner. His mood was reported as down with congruent affect of normal range and intensity. No lability was noted. He was alert and appeared fully oriented, but was not formally tested. No intellectual deficits were noted. Thought processes were clear, logical, and goal-directed. The Veteran denied suicidal/homicidal ideation and audio/visual hallucinations. No psychosis or delusional content was noted. Insight and judgment were poor/fair. In August 2015 the Veteran submitted statements from his sons, sister and brother-in-law. In the letters, they outline a history of depression, anxiety, anger and withdrawal, and that the Veteran had employment problems throughout his lifetime. They also note a history of substance abuse. His sons described a few episodes of violence on the Veteran's part, but with no harm resulting to anything other than property. In June 2015, the Veteran testified before the Board. The Veteran's agent acknowledged that he and the Veteran had discussed the applicable schedular criteria for evaluating the Veteran's psychiatric disabilities. In terms of symptoms, the Veteran described nightmares, trouble sleeping, depression and hypervigilance. He explained that he walked his property at night with his dogs, and noted that his wife would not allow him to have guns. He stated that he had a "really bad temper." In terms of depression, the Veteran described problems with sleeplessness and problems focusing. He related that he thought of killing himself "a lot of times," and that but for his family he would "probably already be gone." He offered a history of suicide attempts through overdose in 1970, 1972, and 1975, but nothing recent. He denied that he was hospitalized and testified that his wife was a nurse, who helped him. In terms of temper, the Veteran related that he had probes with anger, and that something would set him off every day. He offered a remote history of legal trouble in 1969 or 1970, but nothing recent. With respect to anxiety, the Veteran related a daily history of anxiety attacks, described as involving shortness of breath and getting "real nervous." He averaged about 4 hours of sleep with the assistance of medication, but 2 1/2 otherwise. In terms of social activity, the Veteran noted that he came from a large family, with 13 siblings, but did not like most of them, or go to family reunions. He described his family as involving mainly his wife and children, and that he avoided crowds. He stated that he did not socialize often, but had a group of friends that would come to his house, throw darts and work on each other's cars "and stuff." In August 2015, his spouse submitted a personal statement as well, in which she related a history of the Veteran's inability to keep a job for more than 2 months at a time. She also described sleep problems, panic attacks and substance abuse. She stated that the Veteran avoided crowds and avoided travelling too far from home. She and the Veteran had been separated and married four times. She related that she had required the Veteran to remove any guns from the house, out of fear that he may hurt someone. She related that it had been hard to live with him. A statement from an acquaintance of the Veteran, E.D.P, received by VA in December 2015 documents impressions of hypervigilance, where the Veteran would patrol his property in the morning routinely. The acquaintance also outlined a history of avoiding crowds and stores, as well as depression. He noted that the Veteran had employment problems and that he did not get along well with some of his neighbors. A January 2016 personal statement from J.W.P. documents impressions of anger. J.W.P. related that he had worked with the Veteran for 15 years, and that the Veteran had had problems with authority figures, and that the Veteran had "flown of the handle" a few times and quit a job. Following the Board's remand, the Veteran was afforded a VA psychiatric examination in March 2016. Examination at that time resulted in diagnoses of PTSD and marijuana use disorder. Although the examiner diagnosed more than one mental disorder, he noted that "symptoms of the secondary diagnosis of Cannabis Use Disorder cannot be accurately enumerated because the Veteran's report of use is extremely variable," ranging from chronic and daily to not in the past year. In terms of characterization the Veteran's level of occupational and social impairment with respect to all diagnoses, the examiner characterized it as "occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation." In terms of symptoms, he identified depressed mood, anxiety, suspiciousness, panic attacks that occur weekly or less often, chronic sleep impairment, mild memory loss, such as forgetting names, directions or recent events, flattened affect, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, including work or a work like setting, inability to establish and maintain effective relationships, suicidal ideation, obsessional rituals which interfere with routine activities, impaired impulse control, such as unprovoked irritability with periods of violence. On MSE in March 2016, the Veteran presented as a well-nourished white male and was alert and well oriented to all spheres of consciousness. His mood was euthymic, described by the Veteran as "bored." His affect was mildly elevated, and consistent with the nervousness that may accompany an examination. He claimed that he was sad and angry all they time, but appeared pleasant and euthymic at the examination. He described trouble functioning around others due to anxiety, and explained that he drove a truck as a profession to enable him to be alone. He claimed that he frequently thought of suicide. He explained that his suicidal thoughts might have been "very brief." He described his reasoning for seeking increased in disability as "because [he]deserve[d] it," noting that he was not "screwed up" when he went in the Army. He denied homicidal thought, but related that his wife took his guns because he once threatened to shoot a man who provoked and pushed him. He described an active lifestyle with home repair, camping, fishing, and motorcycle riding, along with small animal care and interacting with family including grandchildren. He claims to sleep about 7 hours per night with prescribed trazadone, and that he typically awakes early because early rising is part of a trucker's live. His intelligence was estimated from logic and math skills to be in the average range. He reported mild memory impairment, contrary to the examination results in which he recalled 3/3 items at zero delay and 2/3 at 5 minutes and an intervening task. He recalled 8 digits forward and 5 backwards, both above average. He could perform both rote and non-rote mental multiplication but struggled with serial subtractions. Thought flow was spontaneous, and content was goal and symptom-oriented. In March 2016, VA also obtained an opinion related to the impact of the PTSD on employment. In pertinent part, the opinion states that in the examiner's opinion, the Veteran "is positive for PTSD at a moderate level of impairment, and the criteria for unemployable status is not reached." The examiner noted that the "[V]eteran's reported symptoms varied widely according to records" and that only in "one instance (10/30/2012) did he claim anything related to suicide other than brief ideation," while then claiming actual attempts by overdose and by hanging. The examiner found the inconsistency to be marked, noting that during interview the Veteran claimed suicidal thought but then modified his statement to "brief" thoughts when shown evidence of denials in the clinical records. The March 2016 examiner noted that the Veteran claimed to be unable to sustain work around others and to be unemployable, but stated that his "assessment does not reach concurrence, at least for psychological reasons." Along these lines, the examiner noted that the Veteran was a professional trucker until he retired at 60 due to COPD. The examiner noted that the occupation of over the road trucker involved at least a moderate skill level, and that the Veteran appeared to retain those skills. He reiterated that the Veteran presented well without distress, and that although the Veteran claimed that he could not relax around others, he was observed later the same day asleep in a very crowded waiting room. The examiner noted that the Veteran and his wife had just remodeled their home. The Veteran reported that he went fishing at least twice monthly, enjoyed camping and animal care, and rode his motorcycle in addition to interacting with family. In the examiner's opinion, he found that this his appeared in his opinion "to describe a rich, full life for a competent man." He concluded that any impairment due to PTSD was considered mild to moderate. Here, the AOJ utilized he March 23, 2016, examination report to assign a 70 percent disability evaluation for the service-connected PTSD, based on the results of the March 23, 2016, VA examination. Hart, supra. The results of that examination document symptoms consistent with a 70 percent evaluation, inasmuch as it discloses near-continuous depression, and impaired impulse control, and difficulty to adapting in stressful circumstances, an inability to establish and maintain effective relationships, particularly in a work-like setting, where he described difficulty in stressful circumstances. As outlined above, in order to substantiate such an evaluation, symptoms indicative of occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, must be shown. Those symptoms are outlined above, but notably include symptoms such as suicidal ideation, obsessional rituals which interfere with routine activities, 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), neglect of personal appearance and hygiene, difficulty in adapting to stressful circumstances (including work or a work-like setting), inability to establish and maintain effective relationships. Mauerhan, supra. In resolving any doubt in the Veteran's favor, the Board concludes that prior to March 23, 2016, a 70 percent schedular evaluation is warranted. VA clinical evidence and examinations dated prior to this date generally disclose symptoms of sleep impairment, panic attacks more than once per week, depression, anxiety, low energy and appetite, disturbances of motivation of mood, difficulty, but not inability, in establishing and maintaining work-place relationships, hypervigilance, and apparent mild memory loss. The Veteran has a history of divorce and remarriage times 4, and a history of difficulty with relationships at work. He has a some friends, with whom he socializes with at his house, and apparently regularly goes fishing a couple of times per month. However, it appears that the Veteran has largely kept to himself and stays near his home. There is a history of anger and violence, albeit fairly infrequent. SSA examination in August 2010 showed moderate limitation of the ability to understand and carry out detailed instructions, although the Veteran could perform simple and complex tasks with supervision. The SSA evaluation also notes a "marked ability to deal appropriately with the general public." November 2010 and December 2010 VA records reflect homicidal and suicidal ideation, with the Veteran reporting his fear of acting out in violence. In October 2012, Dr. Rubin noted that the Veteran presented with significant anxiety and depression, with suicidal ideation, and assessed MDD and PTSD, with a GAF of 50. Suicidal ideation is apparent, and the Veteran's reported suicide attempts are remote and largely irrelevant. The Veteran offers a daily history of panic attacks. Under these circumstances, the Boar concludes that PTSD has manifested by symptoms productive of occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to symptoms of suicidal ideation, near-continuous panic or depression, impaired impulse control, and difficulty in adapting to stressful circumstances (including work or a work-like setting), inability to establish and maintain effective relationships. Thus, prior to March 23, 2016, a 70 percent evaluation is warranted. Hart, supra. In this decision, the Veteran has been granted a 70 percent evaluation for the period prior to March 23, 2016, and had been previously been assigned a 70 percent evaluation for the period from March 23, 2016. The Board must now address whether an the next higher 100 percent schedular evaluation is warranted throughout the entire applicable period. In order to substantiate a 100 percent schedular evaluation, there must be evidence of total occupational and social impairment due to symptoms such 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; disorientation to time or place; memory loss for names of close relatives, own occupation or own name. At no point has the evidence supported the award of a 100 percent disability evaluation. In terms of occupational impairment, the Veteran worked until March 2009, when he was either laid off, or retired due to COPD. The Board acknowledges the GAF score of 49 in May 2010 in the SSA records, with the Veteran having marked inability to deal with the general public, as well as Dr. Rubin's opinion that the Veteran's PTSD with MDD resulted in an inability to maintain competitive employment. Along these lines it is apparent that service-connected psychiatric disability impaired employment, as outlined above. Moreover, with respect to social impairment, the Veteran has consistently maintained relationships with his children and wife, socializes with friends at his house and goes fishing. At no point has symptomatology such as that required for the assignment of a 100 percent schedular evaluation been shown. Although the Veteran reported "big bangs" and seeing shadows on a singular occasion, there is no other evidence of persistent delusions or hallucinations. The Veteran has exhibited a tendency for anger and has a history of outbursts with property damage on at least one occasion. However, he has never been described as being a persistent danger to himself or others. He has not been hospitalized for his psychiatric disability. He has identified frequent thoughts of suicide, recently, with a remote history of reported suicide attempts by overdose. A history of mild memory loss such as forgetting names, directions or recent events is noted, as well is the indication in the SSA records that the Veteran would have problems with detailed instructions and tasks. However, there is no indication that the Veteran was ever disoriented as to time or place, or that he had more severe memory loss, to the extent that he forgot the names of close relatives, his occupation or his name. Under these circumstances, total occupational and social impairment is not shown. A 100 percent schedular evaluation is therefore denied. Hart, supra. Bilateral Hearing Loss Evaluation Evaluations of hearing impairment range from zero to 100 percent based on organic impairment of hearing acuity. Auditory acuity is gauged by examining the results of controlled speech discrimination tests, together with the results of pure tone audiometric tests in the frequencies of 1000, 2000, 3000, and 4000 Hertz. To evaluate the degree of disability, the rating schedule establishes 11 auditory acuity levels ranging from level I, for essentially normal acuity, through level XI, for profound deafness. Tables VI (or VIa) and VII are used to calculate the rating to be assigned. 38 C.F.R. § 4.85. Under 38 C.F.R. § 4.86, when the pure tone threshold at each of the four specified frequencies of 1000, 2000, 3000, and 4000 Hertz is 55 decibels or more, Table VI or Table VIa is to be used, whichever results in the higher numeral. 38 C.F.R. § 4.86(a). Additionally, when the pure tone threshold is 30 decibels or less at 1,000 Hertz, and 70 decibels or more at 2,000 Hertz, Table VI or Table VIa is to be used, whichever results in the higher numeral. Thereafter, that numeral will be elevated to the next higher Roman numeral. Each ear is to be separately evaluated. 38 C.F.R. § 4.86(b). In connection with his October 2009 claim for an increased evaluation, the Veteran was afforded a VA examination in November 2009. On VA audiological testing pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 10 30 60 75 LEFT 15 15 50 60 80 Pure tone averages were 44 for the right ear and 51 for the left ear. Speech audiometry revealed speech recognition ability of 90 percent in the right ear and of 84 percent in the left ear. The examiner noted no effect of the disability on the claimants usual occupation as he was not working, but noted that he had a decreased ability to hear or understand the TV, conversations and the telephone. See Martinak v. Nicholson, 21 Vet. App. 447, 454-55 (2007). The Veteran was also afforded a VA examination in August 2011. On VA audiological testing pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 20 10 40 55 60 LEFT 20 20 45 60 70 Pure tone averages were 42 for the right ear and 49 for the left ear. Speech audiometry revealed speech recognition ability of 96 percent in the right ear and of 96 percent in the left ear. The examiner remarked that the Veteran's degree of hearing loss may cause difficulty communicating in adverse listening environments (i.e. background noise) but would not interfere with employment. The examiner found no impact on the ordinary conditions of daily life, including the ability to work. Martinak, supra. The Veteran was gain afforded a VA examination in February 2014. See Virtual VA records system. On VA audiological testing pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 35 30 35 55 55 LEFT 20 20 45 55 75 Pure tone averages were 43.75 for the right ear and 48.75 for the left ear. Speech audiometry revealed speech recognition ability of 88 percent in the right ear and of 84 percent in the left ear. The Veteran remarked that his hearing loss impaired his ability to tune motors when he worked as a truck driver. Martinak, supra. In June 2015, the Veteran testified that he had difficulty hearing low voices and with background noise. He felt the condition had stayed about the same since his last VA examination. Nevertheless, the Board noted indication of worsening, and remanded the claim for an examination. Following the Board's October 2015 remand, the Veteran was scheduled for a VA audiological examination in March 2016 to address the severity of his bilateral hearing loss. The Veteran was notified of the scheduling of the VA examination, and did not attend. He has not requested another VA examination. Accordingly, the Board will proceed based upon the evidence of record. See 38 C.F.R. § 3.655. A compensable evaluation for the Veteran's bilateral hearing loss is not warranted under the circumstances. The November 2009 VA audiometrics yield Numeric Designations for the Veteran's right and left ear hearing loss of I and II, respectively. The August 2011 VA audiometrics result in Numeric Designations for the right and left ear of I and I, respectively. The February 2014 VA audiometrics result in Numeric Designations for the right and left ear of II and II, respectively. 38 C.F.R. § 4.85, Table VI. These numerical designations, when applied to 38 C.F.R. § 4.85 Table VII, yield a non-compensable evaluation. The audiometrics do not demonstrate any exceptional pattern of hearing loss. See 38 C.F.R. § 4.86(b). This has been true throughout the course of this appeal. Accordingly, a compensable evaluation is not warranted for any period of time that is covered by this claim. Hart, supra. Extraschedular Consideration According to the regulation, an extraschedular disability rating is warranted based upon 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 that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1) (2015). An exceptional case is said to include such factors as marked interference with employment or frequent periods of hospitalization as to render impracticable the application of the regular schedular standards. See Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is 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. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluations for the service-connected conditions are inadequate. A comparison between the level of severity and symptomatology of the Veteran's bilateral hearing loss disability and PTSD, panic disorder, and MDD, with alcohol abuse in remission and marijuana dependence, with the established criteria shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology. The criteria for evaluation of bilateral hearing loss particularly contemplate his specific symptoms of having difficulty hearing in real life settings, such as those described by the Veteran. The criteria related to evaluation of mental disorders, specifically contemplate symptoms such as those exhibited by the Veteran, as well as the severity of his occupational and social impairment. Therefore the criteria adequately address the severity of the disabilities. The decibel loss and speech discrimination ranges designated for each level of hearing impairment in Tables VI and VIA were chosen in relation to clinical findings of the impairment experienced by veterans with certain degrees and types of hearing disability. In support of this finding, the Board points to the regulatory history of 38 C.F.R. §§ 4.85 and 4.86. In this regard, the rating criteria for hearing loss were last revised, effective June 10, 1999. See 64 Fed. Reg. 25206 (May 11, 1999). In forming these revisions, VA sought the assistance of the Veteran's Health Administration (VHA) in developing criteria that contemplated situations in which a Veteran's hearing loss was of such a type that speech discrimination tests may not reflect the severity of communicative functioning these veterans experienced or that was otherwise an extreme handicap in the presence of any environmental noise, even with the use of hearing aids. VHA had found through clinical studies of veterans with hearing loss that when certain patterns of impairment are present, a speech discrimination test conducted in a quiet room with amplification of the sounds does not always reflect the extent of impairment experienced in the ordinary environment. The decibel threshold requirements for application of Table VIA were based on the findings and recommendations of VHA. The intended effect of the revision was to fairly and accurately assess the hearing disabilities of veterans as reflected in a real life industrial setting. 59 Fed. Reg. 17295 (April 12, 1994). The Board notes that under Johnson v. McDonald, 762 F.3d 1362 (2014), a Veteran may be awarded an extraschedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the individual conditions fails to capture all the service-connected disabilities experienced. The Veteran has not raised any assertions, nor is there any evidence that suggests that he has symptoms outside of the rating criteria which specifically provide for the evaluation of these disabilities based upon their symptoms, severity and economic impairment . Accordingly, referral for extraschedular consideration is not warranted. In short, there is nothing in the record to indicate that the service-connected disability on appeal causes impairment with employment over and above that which is contemplated in the assigned schedular rating. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (noting that the disability rating itself is recognition that industrial capabilities are impaired). The Board, therefore, has determined that referral of this case for extra-schedular consideration pursuant to 38 C.F.R. 3.321(b)(1) is not warranted. ORDER Entitlement to a 70 percent, but no greater, evaluation is granted for PTSD, panic disorder, and MDD, with alcohol abuse in remission and marijuana dependence prior to March 23, 2016, subject to the laws and regulations governing the award of monetary benefits. Entitlement to a disability evaluation in excess of 70 percent for PTSD, panic disorder, and MDD, with alcohol abuse in remission and marijuana abuse is denied. Entitlement to a compensable evaluation for bilateral hearing loss disability is denied. REMAND Once VA provides an examination, it must be adequate or VA must notify the Veteran why one will not or cannot be provided. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). An examination is adequate if it "takes into account the records of prior medical treatment, so that the evaluation of the claimed disability will be a fully informed one." Barr, 21 Vet. App. at 311 (quoting Green v. Derwinski, 1 Vet. App. 121, 124 (1991)). Moreover, an examination must be based upon consideration of the Veteran's prior medical history and examinations. Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). The Secretary has an affirmative duty to gather the evidence necessary to render an informed decision on a claim. Douglas v. Shinseki, 23 Vet. App. 19 (2009). The Veteran was examined in September 2010, February 2014 and most recently in March 2016, to address the severity of his service-connected left knee disability, sprain, left knee status post-surgery with scars, which has been evaluated as 10 percent disabling. The examination reports reflect a history of surgery to the left knee, an apparent meniscectomy, and scarring and meniscal residuals associated with the disability have apparently been considered, with the scars being non-compensable. The March 2016 examination report also documents instability of the left ACL. Based upon a review of the examination reports, it is unclear as to whether the history of instability of the ACL is a separate and distinct disability, or rather a progression of the knee sprain, status-post surgery with scars. 38 C.F.R. § 4.14 (2015) (the use of manifestations not resulting from service-connected disease or injury in establishing the service-connected evaluation ... is to be avoided). A separate evaluation could be warranted for instability of the knee. See VAOPGCPREC 23-97. Accordingly, the examination report is returned for clarification. 38 C.F.R. § 4.2. According to Correia v. McDonald, 28 Vet. App. 158 (2016), VA musculoskeletal examinations must include joint testing for pain on both active and passive motion, in weight-bearing and nonweight-bearing, and if possible, with range of motion measurements of the opposite undamaged joint. Therefore, after a review of the September 2010, February 2014, and March 2016 VA examination reports, the Board also finds that a remand is also necessary to provide the Veteran with a VA examination that tests the range of motion in active motion, passive motion, weight-bearing, and nonweight-bearing, for the joint in question, i.e. the left knee, and any paired joints, i.e. the right knee. As the evaluation assigned for the Veteran's left knee disability may impact upon the Veteran's claim of entitlement to a TDIU, the Board finds the issues to be inextricably intertwined. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are "inextricably intertwined" when they are so closely tied together that a final Board decision cannot be rendered unless both issues have been considered). Accordingly, the matter is deferred. Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a VA examination to determine the extent and severity of his service-connected left knee disability. All indicated studies, including range of motion studies in degrees, should be conducted, and all findings should be reported in detail. Tests of joint motion against varying resistance should be performed. The extent of any incoordination, weakened movement and excess fatigability on use should be described. The examiner is requested to identify any objective evidence of pain or functional loss due to pain. The specific functional impairment due to pain should be identified, and the examiner should be requested to assess the extent of any pain. The examiner should test the range of motion in active motion, passive motion, weight-bearing, and nonweight-bearing for the left knee. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. The examiner should also express an opinion concerning whether there would be additional limits on functional ability on repeated use or during flare-ups, and, if feasible, express this in terms of additional degrees of limitation of motion on repeated use or during flare-ups. If this is not feasible, the physician should so state and explain why. The examiner should also indicate whether the left knee sprain, status-post surgery with scars, has manifested by lateral instability and/or subluxation. If lateral instability or subluxation is noted, the examiner should comment on the severity of such instability and/or subluxation including the duration and frequency of such manifestations. The examiner should address any meniscal involvement, to include dislocated semilunar cartilage with frequent episodes of "locking," pain and effusion into the joint and symptomatic removal of the semilunar cartilage. In addressing any instability of the left ACL, the examiner is advised that "when change is made of a previously assigned diagnosis or etiology must be kept in mind" and "[t]he aim should be the reconciliation and continuance of the diagnosis or etiology upon which service connection for the disability had been granted." 38 C.F.R. § 4.13. In this regard, the examiner is asked to comment on whether instability of the left ACL is a manifestation of the service-connected sprain, left knee status-post surgery with scars, a progression thereof, or a change in diagnosis. See 38 C.F.R. § 4.13. Any evaluations, studies, or tests deemed necessary by the examiner should be accomplished and any such results must be included in the examination report. A complete rationale for any opinion expressed must be provided. If the examiner is unable to reach an opinion without resort to speculation, he or she should explain the reasons for this inability and comment on whether any further tests, evidence or information would be useful in rendering an opinion. 2. After the development requested above has been completed to the extent possible, review the record and readjudicate the Veteran's claims. If any benefit sought on appeal remains denied, the Veteran and his agent should be furnished a SSOC that considers any evidence associated with the claims file since the last SSOC, and given the opportunity to respond thereto before this case 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). ______________________________________________ MICHAEL A. PAPPAS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs