Citation Nr: 18141462 Decision Date: 10/10/18 Archive Date: 10/10/18 DOCKET NO. 15-23 389A DATE: October 10, 2018 REMANDED Entitlement to an initial evaluation in excess of 10 percent disabling for sinusitis is remanded. Entitlement to an initial evaluation in excess of 10 percent disabling for depressive disorder, not otherwise specified, is remanded. Entitlement to an evaluation in excess of 10 percent disabling for chondromalacia patella, right knee, is remanded. Entitlement to an evaluation in excess of 10 percent disabling for chronic lumbosacral strain/sprain with sciatica of left lower extremity, is remanded. REASONS FOR REMAND The Veteran served on active duty from December 1986 to December 1990. In September 2018, the Veteran appeared at a videoconference hearing before the undersigned Veterans Law Judge. 1. Entitlement to an initial evaluation in excess of 10 percent disabling for sinusitis is remanded. 2. Entitlement to an initial evaluation in excess of 10 percent disabling for depressive disorder, not otherwise specified, is remanded. 3. Entitlement to an evaluation in excess of 10 percent disabling for chondromalacia patella, right knee, is remanded. 4. Entitlement to an evaluation in excess of 10 percent disabling for chronic lumbosacral strain/sprain with sciatica of left lower extremity, is remanded. The Board finds that additional development is needed prior to final adjudication of the issues on appeal. First, based on statements made at the September 2018 hearing, the Board finds that there are outstanding VA and private treatment records that must be obtained and associated with the claim file. In addition, at the hearing, three pages of medical records were associated with the record, including chiropractic and radiology records. However, these treatment records do not appear in the electronic claim file. Upon remand, these documents should be associated with the record. If they are no longer available, the Veteran should be given another opportunity to submit them. Second, at the hearing, the Veteran noted a worsening of her symptoms. For example, she indicated that because of her back, she has missed work, been issued a standing desk, and experienced a loss of bladder control. Her right knee is unstable and she loses balance, is unable to run, and experiences increased pain. Regarding her sinusitis, she has experienced an increase in nose bleeds and has headaches once a week, sometimes more. She has also missed work. Finally, for her depressive disorder, her medication has increased and she is not sleeping well and is forgetful. Under these circumstances, VA cannot rate the service-connected disability without further medical clarification. Hence, the Veteran is entitled to a new VA examination. See, e.g., Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994). The matters are REMANDED for the following action: 1. After securing any necessary consent forms from the Veteran, obtain any outstanding treatment records, to include any VA and/or private treatment records, pertaining to the issues on appeal. In particular, the Board notes that at the hearing, three pages of medical records should have been associated with the record, including chiropractic and radiology records. However, these treatment records do not appear in the electronic claim file. Upon remand, these documents should be associated with the record. If they are no longer available, the Veteran should be given another opportunity to submit them. All efforts to obtain treatment records should be documented in the claim file. If any records could not be obtained, this should be noted in the claim file. 2. Upon completion of the above, schedule the Veteran for the appropriate examinations to determine the current severity of her service-connected disabilities. In particular, the Board asks that the Veteran’s contentions regarding the worsening of her disabilities be considered, including her contentions that: (a) because of her back, she has missed work, been issued a standing desk, and experienced a loss of bladder control; (b) her right knee is unstable and she loses balance, is unable to run, and experiences increased pain; (c) regarding her sinusitis, she has experienced an increase in nose bleeds and has headaches once a week, sometimes more. She has also missed work; and (d) her depressive disorder medication has increased and she is not sleeping well and is forgetful. Finally, regarding the Veteran’s right knee and spine disabilities, the Board asks that the following be addressed: 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 is asked specifically to provide range of motion testing (ROM) for the right knee and spine for active motion, passive motion, weight-bearing, and nonweight-bearing. Full ROM testing also must be conducted on the opposite joint unless the opposite joint is damaged, which includes any disorder that would make the joint in question abnormal. If the opposite joint is determined to be damaged, and no ROM on testing is conducted, this must be explained in the report. In addition, for both the right knee and opposite joint, and the spine, the examiner must discuss pain for ROM movements on active, passive, and repetitive use testing. The examiner is asked to address the following questions: (a) Are any ROM movements painful on active, passive, and repetitive use testing? If yes, identify whether active, passive, and repetitive use. (b) If yes (there are painful movements), does the pain contribute to functional loss or additional limitation of ROM? Please further describe the functional loss or additional limitation of ROM. (c) If no (the pain does not contribute to functional loss or additional limitation of ROM), explain why the pain does not contribute. In addition, for both the right knee and opposite joint, and the spine, the examiner must discuss pain when used in weight-bearing or in nonweight-bearing. The examiner is asked to address the following questions: (a) Is there pain when the joint is used in weight-bearing or nonweight-bearing? If yes, identify whether weight-bearing or nonweight-bearing. (b) If yes (there is pain when used in weight-bearing or nonweight-bearing), does the pain contribute to functional loss or additional limitation of ROM? Please further describe these limitations. (c) If no (the pain does not contribute to functional loss or additional limitation of ROM), explain why the pain does not contribute. In addition, the examiner is asked to address the Veteran’s contentions regarding neurological issues. For all examinations, all necessary development should be taken. The VA examiner should be given access to the claim file. The examiner should state that a review of the claim file was completed. The examiner must provide a comprehensive report including complete rationales for all opinions and conclusions reached, citing the objective medical findings leading to the conclusions. A detailed rationale is requested for all opinions provided. 3. If upon completion of the above action the issues are denied, the case should be returned to the Board after compliance with appellate procedures. E. I. VELEZ Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD K. Foster, Associate Counsel