Citation Nr: 1800805 Decision Date: 01/05/18 Archive Date: 01/19/18 DOCKET NO. 11-26 341 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to a rating in excess of 30 percent disabling for service connected generalized anxiety disorder. 2. Entitlement to a rating in excess of 10 percent disabling for service connected residuals of pilonidal cyst. 3. Entitlement to a rating in excess of 10 percent disabling for service connected dermatitis of the face. 4. Entitlement to a rating in excess of 10 percent disabling for left shoulder injury. 5. Entitlement to service connection for lumbar spine condition to include as secondary to the service connected post-operative residuals of pilonidal cyst. 6. Entitlement to service connection for a bilateral hip condition to include as secondary to the service connected post-operative residuals of pilonidal cyst. 7. Entitlement to service connection for hypertension to include as secondary to service connected generalized anxiety disorder. 8. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service connected conditions. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran, his wife and friend ATTORNEY FOR THE BOARD J. Unger, Associate Counsel INTRODUCTION The Veteran had active duty service from November 1954 to August 1956. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a December 2009 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. The Board previously remanded this claim in July 2016. The Board finds that the Agency of Original Jurisdiction (AOJ) substantially complied with the remand orders in regards to the claims herein decided and no further action is necessary in this regard. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). In February 2017, the Veteran testified at a Board videoconference hearing before the undersigned Veterans Law Judge. A hearing transcript has been associated with the record. Following the hearing, the Veteran submitted additional evidence and waived initial AOJ consideration. 38 C.F.R. § 20.1304 (c) (2017). The Board may therefore properly consider such evidence. The Board notes that the issue of entitlement to a TDIU was not certified for appeal. However, when evidence of unemployability is submitted during the course of an appeal from an assigned rating, a claim for a TDIU will be considered part and parcel of the claim for benefits for the underlying disability. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). In the present case, during his February 2017 Board hearing, the Veteran's representative alleged that his service-connected disabilities rendered him unemployable and argued that the issue of entitlement to a TDIU had been raised. Consequently, the issue of entitlement to a TDIU has been raised. Therefore, as the Board has jurisdiction over such issue as part and parcel of the Veteran's increased rating claims, it has been listed on the first page of this decision. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C. § 7107(a)(2) (West 2014). The issues of entitlement to an increased rating for service-connected dermatitis of the face, and entitlement to service connection for lumbar spine condition, a bilateral hip condition, and hypertension, and a TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the AOJ. FINDINGS OF FACT 1. The Veteran's generalized anxiety disorder is manifested by occupational and social impairment in most areas, as a result of his psychiatric symptomatology, to include depression, anxiety, and suspiciousness, irritability, sleep and memory impairment, disturbances of mood and motivation, and obsessional rituals without more severe manifestations that more nearly approximate total occupational and social impairment. 2. The Veteran's left shoulder injury has been manifested by complaints of pain and dislocation; without scarring, loss of motion, ankylosis of the scapulohumeral articulation, malunion of the humerus, recurrent dislocation of the humerus at the scapulohumeral joint, fibrous union of the humerus, nonunion of the humerus, flail shoulder, or malunion or nonunion of the clavicle or scapula. 3. The Veteran's residuals of pilonidal cyst have been manifested as constant slight or occasional moderate leakage without more severe manifestations such as occasional involuntary bowel movements, necessitating wearing a pad, extensive leakage and fairly frequent involuntary bowel movements, or complete loss of sphincter control. 4. The Veteran has one painful and unstable scar as a result of his pilonidal cyst. CONCLUSIONS OF LAW 1. The criteria for an initial 70 percent rating, but no higher, for generalized anxiety disorder have been met. 38 U.S.C. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9400 (2017). 2. The criteria for an initial 20 percent rating, but no higher, for left shoulder injury have been met. 38 U.S.C. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.10, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5203 (2017). 3. The criteria for an additional 10 percent rating for scar residuals of a pilonidal cyst have been met. 38 U.S.C. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.10, 4.14, Diagnostic Codes 7332-7803, 7335, 7804 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS With respect to the Veteran's claims herein decided, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2017); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). The Board has reviewed all of the evidence in the Veteran's claims file, including his service treatment records (STRs), post-service treatment records, VA examination reports, hearing testimony, and statements submitted in support of his claims. In this regard, the Board notes that, although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, all of the extensive evidence of record. Indeed, it has been held that while the Board must review the entire record, it need not discuss each piece of evidence in rendering a decision. See Newhouse v. Nicholson, 497 F.3d 1298, 1302 (Fed. Cir. 2007); Gonzalez v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board's analysis will focus specifically on the evidence that is needed to substantiate the Veteran's increased rating claims. I. Increased Rating Claims Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, 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. All benefit of the doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. Fenderson v. West, 12 Vet. App. 119 (1999). Staged ratings are appropriate for an increased rating claim whenever the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. However, the evaluation of the same "disability" or the same "manifestations" under various diagnoses is not allowed. See 38 C.F.R. § 4.14. A claimant may not be compensated twice for the same symptomatology as "such a result would overcompensate the claimant for the actual impairment of his [or her] earning capacity." See 38 U.S.C. § 1155; Brady v. Brown, 4 Vet. App. 203, 206 (1993). This would result in pyramiding, contrary to the provisions of 38 C.F.R. § 4.14. However, if a Veteran has separate and distinct manifestations attributable to the same injury, they should be compensated under different diagnostic codes. See Esteban v. Brown, 6 Vet. App. 259 (1994). In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. In determining the degree of limitation of motion, the provisions of 38 C.F.R. §§ 4.10, 4.40, and 4.45 are for consideration. See DeLuca v. Brown, 8 Vet. App. 202 (1995). The basis of disability evaluation 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. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. In Mitchell v. Shinseki, 25 Vet. App. 32 (2011), the Court held that, although pain may cause a functional loss, "pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system." Rather, pain may result in functional loss, but only if it limits the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance." Id., quoting 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45. The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. In Burton v. Shinseki, 25 Vet. App. 1, 5 (2011), the Court found that, when 38 C.F.R. § 4.59 is raised by the claimant or reasonably raised by the record, even in non-arthritis contexts, the Board should address its applicability. A. Generalized anxiety The Veteran is seeking an increased rating in excess of 30 percent for his service-connected generalized anxiety disorder as he contends such disability is more severe than is contemplated by the assigned rating. The Veteran's service-connected generalized anxiety disorder is evaluated under the criteria of Diagnostic Code 9400, which provides that such disability is evaluated pursuant to the General Rating Formula for Mental Disorders. See 38 C.F.R. § 4.130. A 30 percent rating contemplates occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occasional tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal) due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). Id. A 50 percent rating contemplates 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; impairments of short-and long-term memory; impaired judgment; impaired abstract thinking; disturbance of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent evaluation is warranted where 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; 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); inability to establish and maintain effective relationships. Id. A 100 percent evaluation is warranted where 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; memory loss for names of close relatives, own occupation, or own name. Id. As the United States Court of Appeals for the Federal Circuit explained, evaluation under 38 C.F.R. § 4.130 is "symptom-driven," meaning that "symptomatology should be the fact-finder's primary focus when deciding entitlement to a given disability rating" under that regulation. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed.Cir.2013). The symptoms listed are not exhaustive, but rather "serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating." Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In the context of determining whether a higher disability evaluation is warranted, the analysis requires considering "not only the presence of certain symptoms[,] but also that those symptoms have caused occupational and social impairment in most of the referenced areas" - i.e., "the regulation ... requires an ultimate factual conclusion as to the Veteran's level of impairment in 'most areas." Vazquez-Claudio, 713 F.3d at 117-18; 38 C.F.R. § 4.130, DC 9400. Further, when evaluating a mental disorder, the Board must consider the "frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission," and must also "assign an evaluation 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). Furthermore, in Bankhead v. Shulkin, No. 15-2404, 2017 U.S. App. Vet. Claims Lexis 435 (Mar. 27, 2017), the Court held that the language of the general rating formula "indicates that the presence of suicidal ideation alone...may cause occupational and social impairment with deficiencies in most areas." Slip op. at 11. However, as recognized by the Court, VA must engage in a holistic analysis in assessing the severity, frequency, and duration of the signs and symptoms of a veteran's service-connected psychiatric disability, and their resulting social and occupational impairment. 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 Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) and replace them with references to the recently updated DSM-5. See 79 Fed. Reg. 149, 45094 (August 4, 2014). The provisions of the interim final rule apply to all applications for benefits that are received by VA or that were pending before the AOJ on or after August 4, 2014. VA adopted as final, without change, the 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 as of August 4, 2014, even if such claims are subsequently remanded to the AOJ. See 80 Fed. Reg. 53, 14308 (March 19, 2015). In the instant case, the Veteran's claim was certified to the Board in December 2015 and, as such, the DSM-5 applies to his claim. In this regard, the Board notes that the DSM-5 removed reference to Global Assessment of Functioning (GAF) scores. However, such are still considered relevant as they are another component considered to determine the entire disability picture for the Veteran. The GAF scale is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness" from 0 to 100, with 100 representing superior functioning in a wide range of activities and no psychiatric symptoms. Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) (quoting Diagnostic and Statistical Manual of Mental Disorders 32 (4th ed. 1994)). Although GAF scores are important in evaluating mental disorders, the Board must consider all the pertinent evidence of record and set forth a decision based on the totality of the evidence in accordance with all applicable legal criteria. Carpenter, supra. An assigned GAF score, like an examiner's assessment of the severity of a condition, is not dispositive of the percentage rating issue; rather, it must be considered in light of the actual symptoms of a psychiatric disorder (which provide the primary basis for the rating assigned). See 38 C.F.R. § 4.126 (a). Accordingly, an examiner's classification of the level of psychiatric impairment, by word or by a GAF score, is to be considered, but 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. Id.; see also 38 C.F.R. § 4.126, VAOPGCPREC 10-95, 60 Fed. Reg. 43186 (1995). After a review of the record, the Board finds that the Veteran's generalized anxiety disorder results in, at most, occupational and social impairment with deficiencies in most areas, which is indicative of a 70 percent rating, but no higher, for the entire appeal period. Treatment records reflect the Veteran's treatment for anxiety and depression. He takes medication but does not feel that such helps his conditions. An October 2011 treatment note reflects that the Veteran was alert and oriented to person, place and time. The Veteran's mood was stable and his affect full range and congruent. The Veteran's impulse control was within normal limits and there was no evidence of tangentiality or circumstantiality. The Veteran displayed no auditory or visual hallucinations, no suicidal or homicidal ideations and no thought disorders. The Veteran's concentration was fair and his insight and judgment were appropriate. The examiner assigned a GAF score of 60. In January 2012 the Veteran's mood was noted to be brighter and in May 2012, he was noted to be anxious and was again assigned a GAF score of 60. A December 2013 treatment note reflects that the Veteran's mood was depressed and his affect blunted, he was assigned a GAF score of 60 to 65. During the May 2009 VA mental disorder examination, the Veteran reported that he lived with his wife but that they did not have a sexual relationship due to his pain. He reported that he had two grown children with whom he had good relationships. He stated that he did not have very many social contacts but did stay in touch with some friends by phone. The examiner found the Veteran's condition to be moderately severe. Upon examination, the examiner noted that the Veteran was well groomed and appropriately dressed. The Veteran's psychomotor activity was restless and his speech was unremarkable, clear, coherent, and spontaneous. His attitude was cooperative and attentive and his affect was blunted. The Veteran's mood was anxious and dysphoric. He was guarded and not particularly optimistic. His attention was intact and he was oriented to person, place and time. His thought process was unremarkable and his content was ruminations. There was no evidence of any delusions or hallucinations. The Veteran's intelligence was above average and his insight was good. He reported sleep impairment. The examiner noted obsessive/ritualistic behavior, but no panic attacks, homicidal or suicidal thoughts. The examiner assigned a GAF score of 65. During the June 2015 VA Mental Disorders disability benefits questionnaire (DBQ), the examiner diagnosed unspecified depressive disorder with anxious distress. The examiner found that the Veteran's condition caused him 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 reported a 47 year marriage and regular contact with his children. The Veteran noted that he had friends with whom he spoke on the phone but he did not go visit. The Veteran further reported that he worked as an attorney and had done so since 1971. He noted that his physical conditions cause him a lot of distress and significantly reduced his physical activity as well as his social activities. The Veteran reported a depressed mood, and that he felt "useless," but no suicidal intent or plan. He reported sleep disruption at least once a week, but denied any problems with fatigue. He endorsed intermittent irritability, but no physical altercations. He denied any homicidal intent or plan. He did report obsessional rituals such as if he takes one sip of water, he must take three and he engages in counting behaviors. He noted anxiety but no panic attacks. Upon examination, the examiner noted that the Veteran was neatly dressed, well-groomed and his speech was within normal limits. His eye contact was good and his thoughts were logical and goal directed. His thoughts were often focused on his physical health issues. He was oriented to person, place and time and his memory, attention, and abstract reasoning were within normal limits. His mood was "bad" and his affect was mildly anxious and dysphoric. During the July 2016 DBQ, the examiner diagnosed unspecified depressive disorder with anxious distress. The examiner noted that the Veteran's condition resulted in 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 examiner again noted that the Veteran had a long happy marriage with two grown children and that the Veteran was self-employed as an attorney. He noted that the Veteran reported that he used to have a lot of friends but that they have stopped calling or will cancel when they have plans. The Veteran reported that he was very argumentative. Upon examination, the examiner noted that the Veteran suffered from a depressed mood, anxiety, suspiciousness, chronic sleep impairment, and mild memory loss. The examiner noted that the Veteran was neatly dressed with good grooming and hygiene. He was cooperative, alert and oriented. He was talkative, clear and coherent. His mood was uptight and nervous and his affect was congruent. He denied suicidal or homicidal ideations and his thought process was logical and organized and his content was relevant and nonpsychotic. His judgment and insight were good and his attention and concentration were adequate. He reported problems with his memory and that he was constantly depressed. He noted that he felt hopeless. During the February 2017 private mental disorders DBQ, the examiner noted that the Veteran suffered from generalized anxiety disorder and depression. The examiner noted that the Veteran was in constant discomfort from his physical disabilities. The examiner found that the Veteran's anxiety and depression resulted in occupational and social impairment with reduced reliability and productivity. The examiner found that the Veteran suffered from depressed mood, anxiety, suspiciousness, panic attacks that occur weekly or less often, mild memory loss, and disturbances of mood and motivation. The Veteran submitted an additional private mental disorders DBQ in March 2017. The examiner noted that the Veteran suffered from generalized anxiety disorder and depression disorder due to another medical condition. The examiner found the Veteran's conditions resulted in occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication. The examiner found that the Veteran suffered from depressed mood, anxiety, and disturbances of mood and motivation. During the February 2017 hearing, the Veteran testified that he took medication for his anxiety. He also noted that his memory was beginning to fail and that he had trouble sleeping. He testified that he tossed and turned a lot at night and as a result his wife slept in a separate room. The Veteran's wife testified that he was very irritable and negative. The Veteran reported that all of his physical conditions and pain increased his anxiety and that he was closing his legal practice as he could no longer keep up with the requirements. Throughout the appeal the Veteran submitted lay statements in support of his claims. He indicated that his conditions caused him great pain and anxiety. Furthermore, he indicated that he could no longer do the things he loved to do as a result of his increasing conditions. Furthermore, the Veteran has also submitted statements from his doctors describing his treatment and history of anxiety. Based on the forgoing, the Board finds that the Veteran is entitled to a rating of 70 percent, but no higher, for his service-connected generalized anxiety disorder as such disorder has been manifested by occupational and social impairment in most areas, as a result of his psychiatric symptomatology, including include depression, anxiety, suspiciousness, irritability, sleep and memory impairment, disturbances of mood and motivation, and obsessional rituals, without more severe manifestations that more nearly approximate total occupational and social impairment. In this regard, the Board places probative weight on the assessment made by the VA examiners who stated that the Veteran's symptomatology resulted in 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 and the private physician who noted that the Veteran's conditions resulted in occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication. However, the Board also puts great probative weight in the Veteran's hearing testimony where he and his wife indicated that the Veteran's anxiety caused him great distress and highly impacted his life to include significant implications for his memory and irritability. Furthermore, the Veteran's treatment records reveal that he has had continued problems with depression throughout the appeal period and that he had unprovoked irritability and arguments with colleges and friends. The Veteran also reported that he suffered from panic attacks, memory loss, and obsessive or ritualistic behaviors. Thus, based on the totality of the medical and lay evidence, and after resolving all reasonable doubt in favor of the Veteran, the Board finds that the symptoms associated with his service-connected generalized anxiety disorder most nearly approximate the severity and frequency, and duration of the symptomatology contemplated by a 70 percent rating. See 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9400. However, a higher rating is not warranted because the Veteran's generalized anxiety does not result in total social and occupational impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. In this regard, the Board acknowledges the Veteran has experienced occupational and social impairment; however, such have not been considered a total impairment. Specifically, the Veteran has maintained relationships with his family and some friends. Furthermore, the record shows that the Veteran has been cooperative and communicated with VA clinicians, and that he also attended private therapy sessions. Additionally, while the Veteran indicated that he was closing his law practice, the record does not show that his generalized anxiety has resulted in total occupational impairment as the Veteran reported that he still worked and maintained his practice. In addition, while the Veteran has experienced some memory loss, there is no indication that he has lost the names of close relatives, own occupation or own name. Moreover, the record does not indicate that the Veteran experienced 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, or disorientation to time or place. Therefore, the Board finds that the Veteran's generalized anxiety disorder symptomatology is most consistent with an initial 70 percent rating. The Board has resolved all reasonable doubt in the Veteran's favor in reaching all determinations. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. B. Left Shoulder The Veteran contends that a higher rating is warranted for his left shoulder injury. During his February 2017 hearing, he reported that his shoulder was easily and often dislocated. The Veteran's left shoulder injury is rated under Diagnostic Code 5203. As will be noted further herein, VA examinations consistently reflect that the Veteran is right hand dominant. Diagnostic Code 5203 for impairment of the clavicle or scapula provides a 10 percent rating for malunion or nonunion without loose movement. A 20 percent rating is warranted for nonunion with loose movement or dislocation. Evidence relevant to the current level of severity of the Veteran's left shoulder injury includes VA treatment records, VA examination reports dated in August 2009 and May 2015, and the Veteran's hearing testimony. The Veteran's treatment records reflect the Veteran's reports of shoulder pain. In addition, the Veteran reported cracking and popping. During the August 2009 VA examination, the Veteran reported pain in his shoulder accompanied by cracking and popping especially in cold weather. The Veteran did not report any dislocation or subluxation episodes. The examiner found no evidence of arthritis. Upon examination, the examiner noted that there was no objective evidence of pain with active motion and noted range of motion results of left flexion zero to 172 degrees, left abduction zero to 140 degrees, left internal rotation zero to 90 degrees, left external rotation zero to 90 degrees. The examiner found no additional limitation with repetitive motion, objective evidence of pain with repetitive motion, or additional limitations after repetitions of range of motion. X-ray evidence revealed minimal osteopenia, limited excursion of the humeral head within the glenoid between the external and internal rotation views. Minimal increase in the AC distance, small marginal osteophyte off the acromion at the AC joint with the glenohumeral joint preserved and no acute fractures. The examiner noted that the Veteran was employed full time and diagnosed the Veteran with a dislocated shoulder with no significant effects on occupation or daily activities. On the May 2015 Shoulder and Arm DBQ, the examiner noted that the Veteran suffered from a left rotator cuff tear and degenerative arthritis. The Veteran reported that his condition flared up during activity such as working over his chest level, lifting, repetitive gear shifting, and repetitive shoulder movements. Upon examination, the examiner noted range of motion results of flexion zero to 100 degrees, abduction zero to 100 degrees, external rotation zero to 65 degrees, and internal rotation zero to 65 degrees. The examiner found no objective evidence of pain with weight bearing but did not localized tenderness or pain on palpation of the joint and crepitus. The examiner noted that he could not give an opinion about additional limitations during flare ups as the Veteran was not experiencing a flare-up at the time of the examination and the examiner could not make a determination based on subjective data. Muscle strength testing revealed forward flexion and abduction to have active movement against gravity and noted a reduction in muscle strength, but no muscle atrophy. The examiner found no ankylosis. Additional testing revealed positive Hawkins' Impingement test, empty-can test, and lift-off subscapularis tests. The examiner suspected shoulder instability, dislocation or labral pathology, but found no history of recurrent dislocation or subluxation of the glenohumeral joint. The examiner noted a positive crank apprehension and relocation test on the left. The examiner found tenderness or palpation to the AC joint and a positive cross-body adduction test. The examiner noted no impairments of the humerus and no other pertinent physical findings, complications, conditions, signs, symptoms or scars. During the Veteran's February 2017 hearing, he testified that his shoulder was dislocated. He also noted that while he could lift his arm, he was limited in the amount of repetitions. He stated that he could not put dishes in the cabinet or take them out and that he needs his wife's assistance. He testified that his shoulder was often and easily dislocated. He stated that there was no muscle or tendon to hold his shoulder in place and that if he pushed it his shoulder would dislocate. On review of the evidence, the Board finds that a rating of 20 percent, but no higher, is warranted for dislocation of the clavicle or scapula pursuant to Diagnostic Code 5203. As previously mentioned the Veteran testified at his Board hearing that his shoulder was easily and often dislocated. Therefore, the Board finds a 20 percent rating is warranted. In addition, the Board has also considered whether a higher rating is warranted under any other potentially applicable diagnostic code related to the shoulders. However, the Veteran does not have ankylosis of the scapulohumeral articulation, limitation of arm motion below shoulder level, malunion of the humerus, recurrent dislocation of the humerus at the scapulohumeral joint, fibrous union of the humerus, nonunion of the humerus, flail shoulder, or malunion or nonunion of the clavicle or scapula, as documented in the VA examination reports and treatment records. Consideration of Diagnostic Codes 5200, 5201 and 5202 is therefore not warranted. In addition, while degenerative changes of the shoulder have been found on X-ray, there is no evidence of X-ray evidence of involvement of two or more major joints or two or more minor joint groups. Therefore, a higher rating under Diagnostic Code 5003 is not warranted. The Board also notes that it is possible for a Veteran to have separate and distinct manifestations from the same injury which would permit rating under several Diagnostic Codes; however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban, supra. Such is not the case with the Veteran's left shoulder injury. As discussed above, the symptoms associated with the Veteran's disability-namely subjective complaints of pain and dislocation-are contemplated in the application of DC 5203. Moreover, as previously discussed, the Veteran does not have limitation of arm motion, ankylosis of the scapulohumeral articulation, malunion of the humerus, recurrent dislocation of the humerus at the scapulohumeral joint, fibrous union of the humerus, nonunion of the humerus, flail shoulder, or malunion or nonunion of the clavicle or scapula, which could, potentially, support the award of separate ratings in this case. Furthermore, the May 2015 VA examiner determined that the Veteran did not have any other pertinent physical findings, complications, conditions, signs and/or symptoms related to his bilateral shoulder disorders. C. Residuals of pilonidal cyst The Veteran contends that a higher rating is warranted for his residuals of pilonidal cyst. The Veteran's residuals of pilonidal cyst are rated as 10 percent disabling effective September 1, 1961, under 38 C.F.R. § 4.114, Diagnostic Code 7335-7803. In the selection of code numbers assigned to disabilities, injuries will generally be represented by the number assigned to the residual condition on the basis of which the rating is determined. With diseases, preference is to be given to the number assigned to the disease itself; if the rating is determined on the basis of residual conditions, the number appropriate to the residual condition will be added, preceded by a hyphen. 38 C.F.R. § 4.27. The hyphenated diagnostic code in this case indicates that the fistula in ano under Diagnostic Code 7335 is the service-connected disorder and unstable or painful scars under Diagnostic Code 7803 is a residual condition. The diagnostic criteria for disorders of the skin are found at 38 C.F.R. § 4.118, Diagnostic Codes 7801-7805. The Board notes that on September 23, 2008, VA amended the criteria for evaluating scars. See 73 Fed. Reg. 54,708 (Sept. 23, 2008). The amendments are only effective for claims filed on or after October 23, 2008. As the Veteran's claims were received in July 2008, the Board must consider all the applicable regulations, and apply those most favorable to the Veteran. The pre-amended applicable regulations provide that a 10 percent evaluation is due under Diagnositc Code 7801 where a scar (if not on the head, face, or neck) is deep or limits motion, and is at least 6 square inches in size. Under Diagnostic Code 7802, a 10 percent evaluation is warranted where a scar (if not on the head, face, or neck) is superficial, does not cause limitation of motion, and is at least 144 square inches in size. Diagnostic Code 7803 provides a 10 percent rating for scars that are superficial and unstable. Under DC 7804, a 10 percent rating is warranted for scars that are superficial and painful on examination. Under DC 7805, other scars are to be rated based on limitation of function of the part affected. Deep scars are scars associated with underlying soft tissue damage, superficial scars are scars not associated with underlying soft tissue damage, and unstable scars are scars where, for any reason, there is frequent loss of covering of skin over the scar. See 38 C.F.R. § 4.118 (2008). The amended regulations provide under Diagnostic Code 7800, burn scars of the head, face, or neck; scars of the head, face, or neck due to other causes; or other disfigurement of the head, face, or neck. A 10 percent rating is assigned when one characteristic of disfigurement is present and a 30 percent rating is warranted when there is visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features, or; with two or three characteristics of disfigurement. A 50 percent rating for disfigurement of the head, face, or neck is warranted for visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with four or five characteristics of disfigurement. A rating of 80 percent for disfigurement of the head, face or neck with visible or palpable tissue loss and either gross distortion or asymmetry of three or more features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with six or more characteristics of disfigurement. The eight characteristics of disfigurement for purposes of evaluation under 38 C.F.R. § 4.118 are: Scar five or more inches (13 or more centimeters) in length; Scar at least one-quarter inch (0.6 centimeters) wide at the widest part; Surface contour of scar elevated or depressed on palpation; Scar adherent to underlying tissue; Skin hypo-or hyper-pigmented in an area exceeding six square inches (39 square centimeters); Skin texture abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches (39 square centimeters); Underlying soft tissue missing in an area exceeding six square inches (39 square centimeters); Skin indurated and inflexible in an area exceeding six square inches (39 square centimeters). Under Diagnostic Code 7801, burn scar(s) or scars(s) due to other causes, not of the head, face, or neck, that are deep and nonlinear in an area or areas of at least 6 square inches (39 sq. cm.) but less than 12 square inches (77 sq. cm.) warrant a 10 percent rating. Higher ratings are available for scars of greater area. Under Diagnostic Code 7802, burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are superficial and nonlinear in an area or areas of 144 square inches (929 sq. cm.) or greater warrant a 10 percent evaluation. Note (2) under that code provides that if multiple qualifying scars are present, assign a separate evaluation for each affected extremity based on the total area of the qualifying scars that affect that extremity. Under Diagnostic Code 7804, one or two scars that are unstable or painful warrant a 10 percent rating. A 20 percent rating is warranted where there are three or four scars that are unstable or painful, and a 30 percent rating is warranted where there are five or more scars that are unstable or painful. Note (2) for that code provides that if one or more scars are both unstable and painful, add 10 percent to the evaluation that is based on the total number of unstable or painful scars. Note (3) under that provides that scars evaluated under Diagnostic Codes 7800, 7801, 7802, or 7805 may also receive an evaluation under this diagnostic code when applicable. Diagnostic Code 7805 provides that other scars (including linear scars) and other effects of scars evaluated under Diagnostic Code 7800, 7801, 7802, and 7804 require the evaluation of any disabling effect(s) not considered in a rating provided under Diagnostic Codes 7800-04 under an appropriate Diagnostic Code. Diagnostic Code 7335 is rated as for impairment of sphincter control under Diagnostic Code 7332. Under Diagnostic Code 7332 for rectum and anus, impairment of sphincter control, an incompensable rating is provided for healed or slight without leakage. A 10 percent rating is provided for constant slight, or occasional moderate leakage. A 30 percent rating is provided occasional involuntary bowel movements, necessitating wearing a pad. A 60 percent rating is provided for extensive leakage and fairly frequent involuntary bowel movements. A 100 percent rating is provided for complete loss of sphincter control. Evidence relevant to the current level of severity of the Veteran's residuals of pilonidal cyst includes treatment records, VA examination reports dated in May 2015 and March 2017, lay and medical statements, and the Veteran's hearing testimony. Treatment records reflect the Veteran's reports of pain and discharge from the site of the previous surgery for a pilonidal cyst. A July 2011 treatment note reflects minimal discharge. A May 2012 treatment note reflects that the examiner stated that in order to address the Veteran's complaints, surgery was needed in order to place a rotational flap to interpose new tissue to the area. However, the Veteran was not interested in surgery. A July 2012 treatment note reflects the Veteran's complaints of continued almost daily discharge. An October 2012 treatment note reflects that the examiner noted the drainage appeared to be from a fistula. During the May 2015 Rectum and Anus Conditions DBQ and the Scars DBQ, the Veteran reported increased sensitivity to touch and pain with sitting. The examiner diagnosed impairment of the rectal sphincter control and excision of pilonidal cyst. Upon examination, the examiner noted constant slight leakage and occasional moderate leakage. Furthermore, the examiner noted that the Veteran had two associated scars. The examiner found one scar to be painful, but neither scar was unstable. The examiner noted that the scars each measured 1 cm by .5 cm. The examiner opined that the Veteran's scars did not impact his ability to work. During the March 2017 Rectum and Anus Conditions DBQ and Scars DBQ, the examiner diagnosed an anal/perianal fistula. The examiner noted that the entire time that the Veteran had been a patient, approximately 10 years, he had problems resulting from the surgery he underwent in the service. Furthermore, the examiner noted that surgery had been discussed as a treatment option, but due to the Veteran's age, it was not considered a sensible plan. Upon examination, the examiner noted constant slight leakage. The examiner also noted one related scar that was both painful and unstable. The examiner stated that the scar had constant leakage that occasionally lead to infection with significant tenderness. The examiner noted that the scar measured approximately 2.5 cm by 1 cm. Finally, the examiner noted that the Veteran had significant difficulty sitting comfortably due to the location and sensitivity of his condition which impacted his ability to work as he had problems with long meetings, court hearings, and travel. In a May 2012 statement, the Veteran's treating physician stated that the Veteran underwent pilonidal cyst surgery in 1956 and 1957 however it never fully healed and left a scar as well as a defect which drains on a chronic basis. She further stated that it occasionally gets infected and requires antibiotics and occasional lancing to drain the area. During the February 2017 hearing, the Veteran testified that he did not consider his condition a scar but rather a hole in his body. He stated that it caused him great pain and that he had to pack it with cotton balls as it constantly drained. He testified that his scar or hole never fully healed after his surgery in 1956 and that it affects his bowel movements in that he is "going back and forth to the bathroom" constantly. He testified that the wound opens and gets infected. He stated that he takes antibiotics a couple times a year for infections and that he had a hard time sitting comfortably. His wife testified that he had to have a special chair in order to sit comfortably. The Board finds that the Veteran's testimony that his scar is painful and often opens is clinically corroborated by the March 2017 VA examiner's notation that the scar was both painful and unstable. Therefore, under the amended Diagnostic Code 7804-which provides for an additional 10 percent to be added to the rating if the Veteran has one or more scars which are both unstable and painful-an additional 10 percent should be added to the Veteran's rating. However, the Board finds that a higher rating for residuals of pilonidal cyst is not warranted. The Veteran's residuals of pilonidal cyst manifested as a scar which is superficial painful and unstable, and which results in constant slight or occasionally moderate leakage. The Veteran has not alleged, and the record does not otherwise suggest, that there are three or four scars that were unstable or painful. Therefore, the severity of the Veteran's scars is adequately contemplated in the current 10 percent rating plus the additional 10 percent that the Board has now awarded. The Board has also considered whether higher or other separate ratings are warranted under alternative diagnostic codes. However, Diagnostic Code 7800 does not apply as the scarring in question is not on the head, face, or neck. Furthermore, there is no evidence or allegation that his scars were (1) five or more inches, (2) at least one-quarter inch wide at the widest part, (3) adherent to the underlying tissue, (4) hypo- or hyper-pigmented in an area exceeding six square inches, (5) productive of missing underlying soft tissue in an area exceeding six square inches, or (6) productive of indurated and inflexible skin in an area exceeding six square inches. 38 C.F.R. § 4.118, Diagnostic Code 7800. Similarly, Diagnostic Codes 7801 and 7802 are not for application as the Veteran's scar was not deep and did not encompass an area 44 square inches or greater. See 38 C.F.R. § 4.118. Furthermore, the Board notes that the Veteran's representative has argued that the Veteran's residuals of pilonidal cyst should be rated under Diagnostic Code 7332 for impairment of sphincter control rather than or in addition to the Diagnostic Codes for scars. However, the Board notes that the Veteran is already separately service connected and rated under Diagnostic Code 7335 for his impairment of rectal sphincter control associated with his post-operative residuals of pilonidal cyst. The Board notes that under Diagnostic Code 7335 a condition is explicitly rated as impairment of sphincter control under Diagnostic Code 7332. Consequently, that pathology is already compensated and "double compensation" thereof is precluded by law. 38 C.F.R. § 4.14; see also Esteban, supra. II. Other Considerations The Board has considered whether staged ratings under Hart, supra, are appropriate for the Veteran's service-connected disabilities; however, the Board finds that his symptomatology has been stable throughout the appeal period. Therefore, assigning staged ratings for such disabilities is not warranted. In making its rating determinations above, the Board has also carefully considered the Veteran's contentions with respect to the nature of his service-connected disabilities, and notes that his lay testimony is competent to describe certain symptoms associated with such disabilities. The Veteran's history and symptom reports have been considered, including as presented in the medical evidence discussed above, and has been contemplated by the disability ratings that have been assigned for his service-connected disabilities. Moreover, the competent medical evidence offering detailed specific findings pertinent to the rating criteria is the most probative evidence with regard to evaluating the pertinent symptoms of the service-connected disabilities addressed above. As such, while the Board accepts the Veteran's testimony with regard to the matters he is competent to address, the Board relies upon the competent medical evidence with regard to the specialized evaluation of functional impairment, symptom severity, and details of clinical features of the service-connected bilateral shoulder disabilities at issue. ORDER A rating of 70 percent, but no higher, for generalized anxiety disorder is granted for the entire appeal period, subject to the laws and regulations governing payment of monetary benefits. A rating of 20 percent, but no higher, for left shoulder injury is granted for the entire appeal period, subject to the laws and regulations governing payment of monetary benefits. An additional 10 percent rating, but no higher, for residuals of pilonidal cyst, is granted for the entire appeal period, subject to the laws and regulations governing payment of monetary benefits. REMAND Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran's remaining claims so that he is afforded every possible consideration. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. VA's duty to assist includes a duty to provide a medical examination or obtain a medical opinion where it is deemed necessary to make a decision on the claim. 38 U.S.C. § 5103A (d); 38 C.F.R. § 3.159 (c)(4); Duenas v. Principi, 18 Vet. App. 512 (2004); Robinette v. Brown, 8 Vet. App. 69 (1995); McLendon v. Nicholson, 20 Vet. App. 79 (2006). In addition, once VA undertakes the effort to provide an examination when developing a service connection claim, even if not statutorily obligated to do so, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). For below noted reasons, the Board finds that, while the Veteran underwent examinations in May 2015 and March 2017 for his hypertension an addendum opinion is needed. Furthermore, the Board notes that with regards to his claims for service connection for a lumbar spine condition and a bilateral hip condition, no VA examination has been conducted. The Board finds that examinations to determine the nature and etiology of the Veteran's alleged conditions are necessary to decide the claims. With regard to the Veteran's claimed lumbar spine condition and bilateral hip conditions, he has alleged that such are secondary to his service-connected post-operative residuals of pilonidal cyst. A review of the Veteran's treatment records reflects complaints of back pain and a diagnosis for osteoarthritis of the hips. Therefore the low threshold for determining when VA must provide an examination is met. See McLendon, 20 Vet. App. at 79. The Board finds that, in light of the Veteran's various diagnoses, symptoms, and statements with respect to current conditions and potential theories of causation, VA examinations that consider such allegations are warranted. With regard to the Veteran's claimed hypertension, he has alleged that such was caused by his service connected generalized anxiety disorder. The Board notes that the Veteran underwent examinations for his hypertension in May 2015 and March 2017. The May 2015 VA examiner opined that the Veteran's hypertension was not caused by his service connected generalized anxiety disorder, however the examiner did not provide an opinion as to whether or not the Veteran's anxiety aggravated his hypertension. Furthermore, the March 2017 examiner provided no etiological opinion. Therefore, on remand an opinion that considers all the theories of entitlement should be obtained. Relevant to the Veteran's claims for increased rating for his service connected dermatitis, the Court has held that, where the record does not adequately reveal the current state of claimant's disability, fulfillment of the statutory duty to assist requires a contemporaneous medical examination, particularly if there is no additional medical evidence that adequately addresses the level of impairment of the disability since the last examination. Allday v. Brown, 7 Vet. App. 517, 526 (1995). The record reflects that the Veteran underwent VA examinations for his skin condition in August 2009 and May 2015. Furthermore, the Veteran provided a private DBQ in March 2017. The Board notes that the March 2017 examination is current, however the examiner failed to note how often the Veteran used corticosteroids, which could prove crucial in determination the severity of the Veteran's condition. The Board finds that a contemporaneous examination is necessary as the Veteran has alleged significantly worsening symptoms since his last VA examination in May 2015. Specifically with regard to his sebhorric dermatitis, the Veteran has alleged that the condition covers more than 50 % of his face. Such symptoms were not found on his May 2015 VA examination. In addition, as noted the private examination indicated that the Veteran used corticosteroids, however it was not noted for how long. In light of these allegations of worsening symptoms, the Board finds that a remand is required in order to determine the Veteran's current level of impairment with regard to his service-connected right wrist degenerative joint disease. See Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994); VAOPGCPREC 11-95 (1995). The Board finds that the claim for entitlement to a TDIU is inextricably intertwined with the claims remanded herein, the outcomes of which could possibly have bearing on whether the Veteran meets the schedular criteria for TDIU benefits during the entirety of the appeal. See Tyrues v. Shinseki, 23 Vet. App. 166, 177 (2009) (en banc) (explaining that claims are inextricably intertwined where the adjudication of one claim could have a significant impact on the adjudication of another claim); Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. Obtain any outstanding VA treatment records. 2. After obtaining any outstanding records, return the claims file to the May 2015 VA examiner for an examination and addendum opinion. If the May 2015 VA examiner is unavailable, the claims file should be forwarded to an appropriate medical professional to provide the opinion. After reviewing the claims file, the examiner is requested to offer an addendum opinion that specifically addresses the following questions. To the extent possible, the examiner should describe all manifestations and symptoms of the Veteran's service-connected sebhoric dermatitis. In this regard, the examiner should specifically determine whether the Veteran's dermatitis manifested in the following symptoms: (A) Less than 5 percent of the entire body or less than 5 percent of exposed areas affected, and: no more than topical therapy required during the past 12 months. (B) At least 5 percent but less than 20 percent of the entire body, or at least 5 percent but less than 20 percent of the exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12 month period; (C) 20 to 40 percent of the entire body or 20 to 40 percent of the exposed areas affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during the past 12 month period. (D) More than 40 percent of the entire body or more than 40 percent of the exposed areas affected, or; constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12 month period. The rationale for any opinion offered should be provided. 3. The Veteran should be afforded a VA examination to determine the nature and etiology of his claimed lumbar spine condition. The examiner should review the record and note such review in the examination report. The examination should include a review of the Veteran's history and current complaints as well as a comprehensive evaluation and any tests deemed necessary. The examiner is asked to furnish an opinion with respect to the following questions: (A) The examiner should identify all current lumbar spine conditions. (B) For each currently diagnosed lumbar spine condition, is it at least as likely as not (a 50 percent or higher probability) that such disorder is related to his service? (C) If arthritis is diagnosed to be present, the examiner should offer an opinion as to whether arthritis manifested within one year of his service separation in August 1956 and, if so, to describe the manifestations. (D) Finally, were any of the diagnosed lumbar spine conditions caused OR aggravated by the Veteran's service connected post-operative residuals of pilonidal cyst. The examiner must provide a complete rationale for all opinions and conclusions reached. 4. The Veteran should be afforded a VA examination to determine the nature and etiology of his claimed bilateral hip condition. The examiner should review the record and note such review in the examination report. The examination should include a review of the Veteran's history and current complaints as well as a comprehensive evaluation and any tests deemed necessary. The examiner is asked to furnish an opinion with respect to the following questions: (A) The examiner should identify all current bilateral hip conditions. (B) For each currently diagnosed bilateral hip condition, is it at least as likely as not (a 50 percent or higher probability) that such disorder is related to his service? (C) If arthritis is diagnosed to be present, the examiner should offer an opinion as to whether arthritis manifested within one year of his service separation in August 1956 and, if so, to describe the manifestations. If osteoarthritis is not diagnosed, the examiner must explain such in light of the other evidence of record. (D) Finally, were any of the diagnosed bilateral hip conditions caused OR aggravated by the Veteran's service connected post-operative residuals of pilonidal cyst? The examiner must provide a complete rationale for all opinions and conclusions reached. 5. The Veteran should be afforded a VA examination to determine the nature and etiology of his claimed hypertension. The claims file, including a complete copy of this remand, must be made available for review of the Veteran's pertinent medical history. Any evaluations, studies, and tests deemed necessary by the examiner should be conducted. (A) The examiner should opine as to whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran's hypertension is related to his military service. (B) The examiner should also offer an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that hypertension manifested within one year of the Veteran's service separation in August 1956. (C) Finally, was the Veteran's hypertension caused OR aggravated by the Veteran's service connected generalized anxiety disorder? The examiner's attention is directed towards VBA Training Letter 00-07 (July 17, 2000) which states that VA considers systolic pressure of 140 mm Hg or more, or diastolic pressure of 90 mm Hg or more, to be indicative of Stage 1 hypertension. Additionally, the provisions of 38 C.F.R. § 4.104, DC 7101, Note (1) instruct that a diagnosis of hypertension requires 2 or more readings on at least 3 different days. The examiner should consider all evidence of record, including lay statements and medical records. Any opinions offered should be accompanied by clear rationale consistent with the evidence of record. 6. Readjudicate the appeal. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This 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. §§ 5109B, 7112 (West 2014). ______________________________________________ R. FEINBERG Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs