Citation Nr: 1754577 Decision Date: 11/29/17 Archive Date: 12/07/17 DOCKET NO. 13-28 593A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New Orleans, Louisiana THE ISSUES 1. Entitlement to a rating in excess of 50 percent for posttraumatic stress disorder (PTSD). 2. Entitlement to total disability for individual unemployability (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD E. Miller, Associate Counsel INTRODUCTION The Veteran served on active duty in the United States Navy from December 1960 to October 1964 and from December 1964 to September 1970 with service in the Republic of Vietnam. The Veteran had active duty in the United States Army from July 1978 to September 1980. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a February 2011 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in New Orleans, Louisiana (hereinafter Agency of Original Jurisdiction (AOJ)). In October 2014 the Veteran testified at a videoconference hearing with the undersigned Veterans Law Judge (VLJ). A transcript of the hearing is associated with the claims file. This case was last before the Board in July 2015 when it was remanded for further development and to make a determination on TDIU raised by the record. The requested development has been completed and the case has since been returned to the Board for appellate review. The issue of entitlement to TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDING OF FACT The Veteran's service-connected PTSD is manifested by psychiatric symptoms such as sleep impairment, nightmares, difficulty concentrating, irritability, anger management issues, hypervigilance, and difficulty in maintaining social relationships, causing occupational and social impairment with reduced reliability and productivity, but not deficiencies in most areas, or total occupational and social impairment. CONCLUSION OF LAW The criteria for an increased evaluation for PTSD in excess of 50 percent have not been met. 38 U.S.C. § 1155, 5107 (West 2014); 38 C.F.R. § 4.126, 4.3, 4.7, 4.130, Diagnostic Code 9411 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION I. Duty to Notify and Assist The VCAA, codified in part at 38 U.S.C.A. §§ 5103, 5103A, and implemented in part at 38 C.F.R. § 3.159, amended VA's duties to notify and to assist a claimant in developing information and evidence necessary to substantiate the claim. VA's duty to notify was satisfied by letter dated in March 2007. See 38 U.S.C.A. §§ 5102, 5103, 5103A (West 2014); 38 C.F.R. § 3.159 (2017); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). The Veteran was sent a statement of the case (SOC) in August 2013 regarding denial of his claim for increased rating in excess of 50 percent for PTSD. The RO subsequently deemed that SOC inadequate for failing to include certain laws and to evaluate a piece of evidence. The RO issued a supplemental statement of the case (SSOC) in July 2014 to rectify the prior SOC. VA has fulfilled its duty to assist in obtaining identified and available evidence needed to substantiate the claims. Service treatment records (STRs) and all identified and obtainable post-service treatment records have been associated with the record. With respect to the Veteran's claim for entitlement to service connection for PTSD, pursuant to the Board's July 2015 remand, the Veteran was afforded a new VA examination in November 2015. The Board finds that the November 2015 VA examination and its related opinion were thorough and adequate. See Barr v. Nicholson, 21 Vet. App. 303 (2007). The Board concludes that no further assistance to the Veteran in developing the facts pertinent to the claims is required to comply with the duty to assist. The Board will adjudicate the appeal based on the evidence of record. II. Increased rating for PTSD Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule), which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155 (West 2014); 38 C.F.R. § 4.1 (2017). 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. If there is a question as to which evaluation to apply to the Veteran's disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings are sufficiently characteristic to identify the disease and the resulting disability and coordination of rating with impairment of function. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of his disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2017). Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of any disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). The Federal Circuit has also held that the Board must review the entire record, but the law does not require that the Board discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Mental disorders are evaluated under the general rating formula for mental disorders, a specific rating formula presented under 38 C.F.R. § 4.130. In addition, the fourth edition of the American Psychiatric Association's Diagnostic and Statistical Manual for Mental Disorders (DSM-IV) provides guidance for the nomenclature employed within 38 C.F.R. § 4.130. However, effective August 4, 2014, VA amended the portion of its Schedule for Rating Disabilities dealing with mental disorders and its adjudication regulations that define the term "psychosis" to remove outdated references to the DSM-IV and replace them with references to the recently updated Diagnostic and Statistical Manual (Fifth Edition) (the DSM-5). See 79 Fed. Reg. 45,094 (August 4, 2014). VA adopted as final, without change, this interim final rule and clarified that the provisions of this interim final rule do not apply to claims that have been certified for appeal to the Board or are pending before the Board on or before August 4, 2014. See Schedule for Rating Disabilities - Mental Disorders and Definition of Psychosis for Certain VA Purposes, 80 Fed. Reg. 14,308 (March 19, 2015). In the present case, the Veteran applied for service connection for PTSD in 2007, and the RO first certified the Veteran's appeal to the Board on August 21, 2014, which is after August 4, 2014. Thus, the version of 38 C.F.R. § 4.125 conforming to the DSM-5 is applicable in the present case. In any event, the Board will still consider any private or VA examiner's discussion of both the DSM-IV and DSM-5 in adjudicating the current Veteran's PTSD claim, in order to provide the Veteran with every benefit of the doubt. When evaluating a mental disorder, the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission must be considered. 38 C.F.R. § 4.126(a). In addition, the evaluation must be 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. 38 C.F.R. § 4.126(a). When evaluating the level of disability from a mental disorder, the extent of social impairment is considered, but the rating cannot be assigned solely on the basis of social impairment. 38 C.F.R. § 4.126(b). As provided by the General Rating Formula, 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. 38 C.F.R. § 4.130. A 70 percent rating is in order when there is 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 work like setting); and inability to establish and maintain effective relationships. Id. A 100 percent rating is in order when there is 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; and memory loss for names of close relatives, own occupation, or own name. Id. A veteran need not exhibit "all, most, or even some" of the symptoms enumerated in the General Rating Formula for Mental Disorders to warrant the assignment of a higher rating. Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Rather, the use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptomatology contemplated for each rating. Id. In particular, use of such terminology permits consideration of items listed as well as other symptoms and contemplates the effect of those symptoms on the claimant's social and work situation. Mauerhan, 16 Vet. App. at 442. The Federal Circuit has clarified that the General Rating Formula for Mental Disorders requires not only (1) sufficient symptoms of the kind listed in the percentage requirements, or others of similar severity, frequency, or duration, but also (2) that those symptoms cause the level of occupational and social impairment specified in the regulation. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013). The Federal Circuit endorsed an approach whereby the Board would identify the symptoms associated with the service-connected mental health disability, determine whether they are of the kind enumerated in the regulation, and if so, assess whether they result in the level of occupational and social impairment specified by a particular rating. Id. The 50 percent disability rating regulation, in particular, contemplates 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 reduced reliability and productivity. Id. Reading §§ 4.126 and 4.130 together, it is evident that the "frequency, severity, and duration" of a veteran's symptoms must play an important role in determining his disability level. Id. at 117. In evaluating the evidence, the Board has also noted various GAF scores contained in the DSM-IV, which clinicians have assigned. A GAF score is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing DSM-IV at 32). 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 generally 38 C.F.R. § 4.126; VAOPGCPREC 10-95. Higher GAF scores denote increased overall functioning of the individual. For instance, a score of 31 to 40 represents "[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; child frequently beats up younger children, is defiant at home, and is failing at school)." DSM-IV at 46-47. A score of 41 to 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)." Id. A score of 51 to 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)." Id. GAF scores ranging between 61 and 70 reflect some 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, and has some meaningful interpersonal relationships. GAF scores from 71 to 80 reflect transient symptoms, if present, and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument); no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork). Id. The Veteran's service-connected PTSD is currently assigned a 50 percent evaluation pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411 from January 26, 2007. The Veteran filed a notice of disagreement with the initial rating of 50 percent for PTSD in March 2011 after the RO's decision in February 2011, and filed a VA Form 9 in October 2013 after the RO issued a statement of the case in August 2013. In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the current 50 percent evaluation for PTSD is appropriate under Diagnostic Code 9411. 38 C.F.R. § 4.7. That is, the Veteran's service-connected PTSD is manifested by psychiatric symptoms causing occupational and social impairment with reduced reliability and productivity which are indicative of the 50 percent rating criteria. See 38 C.F.R. § 4.130. The Board has also considered additional, similar symptomatology not specifically addressed in the 50 percent criteria under the General Rating Formula, but causing the appropriate level of occupational and social impairment for a 50 percent rating, under the General Rating Formula. See again Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). The evidence of record supports a 50 percent rating for PTSD for the appeal period. In making this determination, the Board has reviewed both the medical and lay evidence of record, including the lay statements from the Veteran and his wife; VA and other treatment records; and the VA examination dated November 2015. The Veteran's medical treatment records for the year 2007 document instances of mental health consultations with VA treatment providers. Overall, the Veteran was assigned a GAF score of 75 on multiple occasions during 2007. The Veteran reported nightmares and that he and his wife slept in separate rooms because he was fighting in his sleep and preventing her from sleeping. As explained above, GAF scores from 71 to 80 reflect transient symptoms, if present, and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument); no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork). Id. The Veteran started group therapy in 2008 for his PTSD and records indicate the symptoms he experienced included anxiety attacks, fear of dying, depression, and nightmares. There were no suicidal or homicidal ideations reported. In June 2008, a treatment provider assessed the Veteran with a GAF score of 53 noting that the Veteran was stressed about his son who had taken up drugs again. The medical treatment provider recommended to the Veteran to participate in psychotherapy for his "family problems." A GAF score of 51 to 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)." The Veteran's wife submitted a statement dated October 2008 in which she describes the Veteran as "increasingly forgetful," and "not the same man" she married. For example, she states she works in different offices and informs her husband daily where she will be but he calls different offices because he can't remember where she said she would be working. She also described the Veteran's active nightmares which include hitting the walls and cursing, and how it is a bad scene for the grandchildren to witness. The Veteran's wife also reported that during a nightmare, the Veteran once grabbed their dog by the throat and threw him out of the bed. She is afraid to sleep with him, and he has hit her while having nightmares. The Veteran was afforded a VA psychiatric examination in December 2010. There were no reports of hospitalizations for psychiatric disorders. The examiner noted the Veteran was currently taking an anti-depressant which the Veteran reported was helpful but did not quell all symptoms, in particular the nightmares. The Veteran reported talk therapy was very helpful. The Veteran reported no close friends at the time of examination. There was no report of suicide attempts, or history of violence or assault. The Veteran's mood was described as "angry, frustrated." Judgment, intelligence, and insight were intact. The Veteran reported sleep impairment due to nocturia and nightmares, to include fighting in his sleep. The Veteran reported anxiety attacks on an almost daily basis. There was no report of suicidal or homicidal ideation. The Veteran was able to maintain good hygiene and perform activities of daily living. The examiner noted that the Veteran recalled seeing a "black angel" who informed the Veteran he would live to be 107 years old and her voice came to him from outside his head. Memory was reported as normal for remote, recent, and immediate. The Veteran relayed that part of the reason he had stopped working was he did not want to be away from home overnight. The examiner assigned a GAF score of 52. Based on the Veteran's symptoms, the examiner endorsed that the Veteran's symptoms were productive of occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks but with generally satisfactory functioning, which equates to a 30 percent disability rating. A May 2011 private medical opinion submitted by the Veteran notates that the Veteran's condition of "Chronic Post Traumatic Stress Disorder, has virtually gone unchanged for many years and is expected to continue." The letter also noted the Veteran to be impulsive, impacting his working life and dealing with people. In the letter, the doctor also describes the Veteran to be "very easily irritated, has constant anxiety attacks, suffers from insomnia, and experiences violent dreams that have caused issues in his marriage." Although the Veteran endorsed passive suicidal ideation at the October 2014 hearing, on suicide risk assessment screenings, the Veteran regularly is considered not at risk, and there are no reports of suicidal ideations in his medical records. The Veteran also contended at the hearing that he had told "the guy" that he had suicidal notions but it was not recorded. At the hearing the Veteran also contended that the findings were inaccurately interpreted, in particular the GAF scores "between 47 to 53" from the time around 2009 to 2010. As explained above, 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 generally 38 C.F.R. § 4.126; VAOPGCPREC 10-95. To the extent that the Veteran may argue or suggest that the clinical data supports an increased rating or satisfies the rating criteria for a higher rating, such assertions fall outside the realm of common knowledge of a lay person. Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). The Veteran also indicated that his wife is a psychiatric nurse, but again, all the evidence of record should be considered beyond GAF scores. The Veteran was afforded a VA psychiatric examination in November 2015. The examiner noted that the Veteran presented to the examination dressed and groomed appropriately. The Veteran exhibited logical and coherent thought processes with fair reasoning and judgment. The Veteran's affect was reported as "spontaneous with some underlying irritability" especially with regard to the VA claims process. The Veteran's memory was reported as "low average concentration in short term memory" which could be related to previous academic level or declining memory with age. The Veteran reported symptoms of nightmares, and psychological distress around water and children, which remind him of Vietnam. The Veteran reported periodic panic attacks and symptoms indicative of a depressive component. The examiner noted that while the Veteran denied suicidal thoughts, he did endorse thinking such as wondering why he was alive, i.e. that he felt he was "just existing." The Veteran denied any homicidal thinking, mania, psychosis, or obsessive compulsive symptoms. The Veteran relayed to the examiner that he had been ejected from group therapy because he became aggressive with another participant. The examiner opined that, while she sees times in the medical record where the Veteran may have "been in more distress" than currently evidenced, she did not see evidence of total occupational and social impairment due to PTSD, or more severe occupational and social impairment with deficiencies in most areas. The examiner described his current level of PTSD as moderate. At a February 2017 appointment, the treatment provider reported that the Veteran's PTSD symptoms were exacerbated by family stress. The treatment provider noted the Veteran was dressed cleanly and with good hygiene. There were no reports of audio/visual hallucinations or suicidal or homicidal ideations. At a March 2017 PTSD appointment, the Veteran reported sleeping poorly, being depressed, and "doing terribly." He stated that he could not work because he was too "irritated." The treatment provider noted that the Veteran arrived at the appointment dressed cleanly and with good hygiene. The Veteran reported his son was in jail which was depressing him. The examiner noted that another participant in the Veteran's group therapy reported the Veteran was in an "explosive" mood. An April 2017 mental health consultation note in VA treatment records documents that the Veteran's sleep was "worse than ever" and he still got anxiety but he described his mood as "pretty good." The Veteran reported he still went fishing. The treatment provider noted the Veteran was dressed cleanly and with good hygiene. There were no reports of audio/visual hallucinations or suicidal or homicidal ideations. At May 2017 appointments the Veteran reported continuing nightmares and that his bed had rails to prevent him from falling out, which he reported had previously resulted in a broken rib. He reported himself to be in a "pretty good mood," although endorsing daily feelings of depression. The treatment provider noted the Veteran self-identified as capable of independence and performance of activities of daily living. The doctor at one appointment reported the Veteran's sleep was "significantly improved with Prazosin." The Veteran fished for recreation, however he reported sometimes arriving at the river and turning around because he was reminded of river patrol in Vietnam. The Veteran presented himself dressed cleanly with good hygiene. There were no reports of audio/visual hallucinations or suicidal or homicidal ideations. In summary, consideration of the above psychiatric symptoms and circumstances reflects occupational and social impairment with reduced reliability and productivity that is indicative of a 50 percent rating. See 38 C.F.R. § 4.130. However, the Veteran does not meet the criteria for a higher 70 percent evaluation for his service-connected PTSD. 38 C.F.R. § 4.7. That is, the medical and lay evidence of record is not indicative of someone with psychiatric symptomatology causing occupational and social impairment, with deficiencies in most areas, which is required for the 70 percent rating. 38 C.F.R. § 4.130. In particular, the Board finds that the Veteran does not have social impairment with deficiencies in most areas as contemplated by a schedular 70 percent evaluation. See 38 C.F.R. § 4.130. In this regard, the Board notes that the Veteran has a reportedly good relationship with his wife of 35 years, and good relations with his family, although he is nervous to allow his grandchildren to spend the night lest they see him having a nightmare, and his son stresses him out due to drug dependency. The Veteran stated he does not have friends, but does talk to some of his fellow group therapy participants in a friendly capacity. The Veteran also reported he goes out with his wife to restaurants and to church, but tends to avoid crowded places. Thus, he can still maintain some relationships. Moreover, the Board notes that the 50 percent evaluation he now has for PTSD encompasses a difficulty in establishing and maintaining effective relationships. The Veteran reports to his medical appointments in a state of good personal hygiene and alert. The records do not reflect reports of suicidal or homicidal ideation, although the Veteran claims he often has passive suicidal thoughts, for example contemplating the notion of driving into a median while he is out driving around. His judgment and abstract thinking capabilities are not impaired. The Veteran's record reflects reports of some memory impairment. In short, the medical or lay evidence of record reveals the Veteran's symptoms more closely match the 50 percent disability rating for PTSD. With regard to occupational impairment, the Board acknowledges that the Veteran reported working full time until 2006 or 2007, and informed a treatment provider in September 2006 that he was thinking of retiring but felt guilty that his wife still worked. In prior records, he reported working full time for many different employers, at one point stating he had held "over 200 jobs." The Veteran's wife also reported he had held many jobs in his lifetime. The Veteran reported he closed his trucking business and started driving a tour bus for a friend's business for a few years, then stopped because he found himself irritated with the clients, which he attributed to his PTSD. The Veteran has been able to work for many years, although he has cycled through many jobs. This goes against a finding of occupational impairment with deficiencies in most areas. The majority of the evidence indicates that even considering the symptoms the Veteran has (passive suicidal ideation, irritability, depressed mood, anxiety, memory impairment, sleep impairment, nightmares, etc.) at no time during this period did the Veteran demonstrate deficiencies in most areas. During this period, the Veteran's judgment and thinking were always noted to be normal. While he has shown difficulty with depression, he has been able to maintain a strong, albeit small, support network and seek professional help when needed. Given these findings, the Board concludes that the weight of evidence shows that the Veteran's symptoms did not meet the criteria required for a rating in excess of 50 percent for PTSD. 38 C.F.R. § 4.130, Code 9411. ORDER Entitlement to a rating in excess of 50 percent for PTSD is denied. REMAND Upon review of the record, the Board concludes that further evidentiary development is necessary. Although the Board sincerely regrets this delay and is appreciative of the Veteran's service to his country, a remand is necessary to ensure VA provides the Veteran with appropriate process and assistance in developing his claim prior to final adjudication. The Veteran was afforded a VA examination for his left knee in November 2015. Subsequently the Veteran underwent total left knee replacement in December 2015 and was awarded a convalescence disability rating of 100 percent from the date of surgery until January 31, 2017. The Veteran's left knee is currently rated at 30 percent from February 1, 2017. As the Veteran is claiming TDIU and has not had an evaluation of this service-connected condition since his surgery and the end of his convalescence period, the VA should afford the Veteran a new examination to determine the level of disability of his left knee and its potential impact on the Veteran's ability to work. The Veteran should also be asked to identify any outstanding treatment records for his left knee disability. Accordingly, the case is REMANDED for the following action: 1. Ask the Veteran to identify any outstanding treatment (to include any private, VA, or military) for his left knee disability. With any assistance required from the Veteran, make appropriate efforts to obtain any outstanding treatment records identified by the Veteran. 2. Thereafter, schedule the Veteran for a VA examination to determine the current severity of his service-connected disability of the left knee by an appropriate medical professional. All appropriate tests and studies shall be conducted. All relevant electronic records, including a copy of this remand, must be sent to the examiner for review. The examination should be conducted in accordance with the current disability benefits questionnaire, to include compliance with 38 C.F.R. § 4.59 as interpreted in Correia. The examiner should report the ranges of motion of the left knee (in degrees) on both active motion and passive motion and in both weight-bearing and non-weight bearing. 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 specifically answer the following questions: (i) What is the extent of any additional limitation in motion (in degrees) of the left knee due to weakened movement, excess fatigability, incoordination, or pain during flare-ups and/or with repeated use? (ii) What impact, if any, does the Veteran's service-connected disability have on his ability to work? The Board recognizes the difficulty in making such determinations but requests that the examiner provide his or her best estimate based on the examination findings and statements of the Veteran, as such is required by the law as interpreted by the Court. The examiner must provide reasons for any opinion given. The examiner is advised that the Veteran is competent to report his symptoms and history, and such statements by the Veteran must be specifically acknowledged and considered in formulating any opinions concerning the severity of his disabilities. 3. Thereafter, readjudicate the TDIU claim remaining on appeal. If the benefits sought remain denied, issue a supplemental statement of the case and provide the Veteran and his representative the requisite period of time to respond. The case should thereafter be returned to the Board for further appellate review, if otherwise in order. 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). ______________________________________________ DAVID L. WIGHT Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs