Citation Nr: 18142445 Decision Date: 10/15/18 Archive Date: 10/15/18 DOCKET NO. 14-44 093 DATE: October 15, 2018 REMANDED Entitlement to a rating in excess of 30 percent for anxiety disorder, not otherwise specified (claimed as PTSD, depression, and hypervigilance) with memory loss, fatigue, irritability, confusion, and sleep problems is remanded. Entitlement to a compensable rating for residuals of a traumatic brain injury (TBI) (with subjective intermittent dizziness) is remanded. Entitlement to a rating in excess of 10 percent for hypothyroidism is remanded. Entitlement to a rating in excess of 10 percent for chronic pityrosporum folliculitis is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from January 1995 to May 1998, from August 2001 to April 2002 and from January 2004 to April 2005, with service in Iraq. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a September 2013 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO) in Hartford, Connecticut. The Veteran presented sworn testimony at a hearing before the undersigned in August 2015. 1. Entitlement to a rating in excess of 30 percent for anxiety disorder, not otherwise specified (claimed as PTSD, depression, and hypervigilance) with memory loss, fatigue, irritability, confusion, and sleep problems is remanded. The Veteran asserts that he is entitled to a rating in excess of 30 percent for his service-connected anxiety disorder, not otherwise specified. VA’s duty to assist includes providing a thorough and contemporaneous medical examination, especially where it is necessary to determine the current level of a disability. The Board notes that the Veteran was last afforded a VA examination to assess the severity of his service-connected anxiety disorder, not otherwise specified, in December 2012. At his August 2015 hearing, the Veteran testified that he experiences anxiety during work as a State Trooper and that his service-connected anxiety disorder is entitled to an increased rating based on its relationship with his service-connected hypothyroidism. See August 2015 Hr’g Transcript, 5-7. In light of the foregoing, the Board finds that a contemporaneous examination is warranted to ensure that the record reflects the current severity of the Veteran’s service-connected anxiety disorder, not otherwise specified. 2. Entitlement to a compensable rating for residuals of a traumatic brain injury (TBI) (with subjective intermittent dizziness) is remanded. The Veteran asserts that he is entitled to a compensable rating for the residuals of his traumatic brain injury, with subjective intermittent dizziness. At his August 2015 hearing, the Veteran testified that he is entitled to a compensable evaluation for his service-connected TBI due to his dizziness and headaches. See August 2015 Hr’g Transcript at 10. The Board notes, the September 2013 rating decision granted the Veteran service connection for residuals of TBI (with subjective intermittent dizziness) and granted service connection for migraines. Additionally, the Veteran was last afforded a VA examination to assess the severity of his service-connected residuals of a TBI (with subjective intermittent dizziness) in December 2012. At his August 2015 hearing, the Veteran testified that he experiences dizziness, especially when he closes his eyes. Additionally, he testified that he experiences migraines at least twice a month and low-grade headaches twice a week. In September 2018, the Veteran was provided a VA examination for his service-connected migraines; however, that examination does not address the Veteran’s dizziness symptoms. With respect to the migraines, as noted, an additional relevant VA examination report was added to the claims file in September 2018 but no supplemental SOC (SSOC) was issued. Therefore, the evidence must be considered by the AOJ in the first instance. With respect to entitlement to residuals of a TBI (with subjective intermittent dizziness), the Board finds that a remand is necessary to obtain a new examination and medical opinion to determine the current severity of the Veteran’s reported intermittent dizziness related to his service-connected TBI residuals. 3. Entitlement to a rating in excess of 10 percent for hypothyroidism is remanded. The Veteran seeks a higher rating for his service-connected hypothyroidism that is currently rated at 10 percent. Additionally, the Veteran testified that the symptoms of his service-connected anxiety disorder and pityrosporum folliculitis are due to his service-connected hypothyroidism. Specifically, he asserts that he is entitled to a 100 percent disability rating for his hypothyroidism based on his symptomatology and that a 100 percent grant would satisfy his claims related to entitlement to a rating in excess of 10 percent for hypothyroidism, entitlement to a rating in excess of 30 percent for anxiety disorder, not otherwise specified and entitlement to a rating in excess of 10 percent for chronic pityrosporum folliculitis as well. The Veteran testified that his physician informed him that additional symptoms due to thyroidism include: anxiety depression, intolerance to cold, skin rashes, loss of sleep, sluggishness, fatigue, and muscle exhaustion. See August 2015 Hr’g transcript at 8-9. Clarity is needed regarding this matter. Additionally, the Veteran was last afforded a VA examination in December 2012. Under the circumstances, the Board finds that VA is required to afford him a contemporaneous VA examination to assess the current nature, extent, and severity of his hypothyroidism. See Palczewski v. Nicholson, 21 Vet. App. 174, 181 (2007); Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). 4. Entitlement to a rating in excess of 10 percent for chronic pityrosporum folliculitis is remanded. The Veteran asserts that he believes that he is entitled to an increase in his disability rating for his service-connected pityrosporum folliculitis based on its relationship to his service-connected hypothyroidism. See August 2015 Hr’g Transcript at 9. The Veteran was last afforded a VA examination in December 2012. Under the circumstances, the Board finds that a contemporaneous VA examination is needed to assess the current nature, extent, and severity of his chronic pityrosporum folliculitis. See Palczewski v. Nicholson, 21 Vet. App. 174, 181 (2007); Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). The matters are REMANDED for the following action: 1. Contact the Veteran and request that he identify any and all outstanding VA and private treatment records related to his anxiety disorder, residuals of a TBI (with subjective intermittent dizziness), hypothyroidism and pityrosporum folliculitis. After obtaining the necessary authorization forms from the Veteran, obtain any pertinent records and associate them with claims file. Any negative response should be in writing and associated with the claims file. 2. Notify the Veteran that he may submit lay statements from himself and from other individuals who have first-hand knowledge, and/or were contemporaneously informed of the nature, extent and severity of his psychiatric disability, hypothyroidism, residuals of his TBI, to include dizziness, and chronic pityrosporum symptoms and the impact of these conditions on his ability to work. The Veteran should be provided an appropriate amount of time to submit this lay evidence. Anxiety Disorder, not otherwise specified 3. Schedule the Veteran for a VA examination to assess the current severity of his service-connected psychiatric disability, diagnosed as anxiety disorder, not otherwise specified. It should be noted that the Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptoms. The examiner should take as truthful, the Veteran’s competent and credible statements regarding the severity of his symptomatology. The examination report should include an account of all manifestations of the Veteran’s service-connected anxiety disorder found to be present and whether those symptoms are related to the Veteran’s service-connected hypothyroidism. The examiner should report all signs and symptoms necessary for rating the Veteran’s anxiety disorder. Hypothyroidism 4. Schedule the Veteran for a VA examination to address the nature and current severity of his service-connected hypothyroidism. The claims folder should be made available to and reviewed by the examiner. All necessary tests should be performed. The examiner is requested to review all pertinent records associated with the claims file. It should be noted that the Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptoms. The examiner should take as truthful, the Veteran’s competent and credible statements regarding the severity of his symptomatology. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. The examiner must attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. To the extent possible, the examiner should identify any symptoms and functional impairments due to hypothyroidism disability alone and discuss the effect of the Veteran’s hypothyroidism disability on any occupational functioning and activities of daily living. If it is not possible to provide a specific measurement, or an opinion regarding flare-ups, symptoms, or functional impairment without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). All findings, along with a fully articulated medical rationale for all opinions, should be set forth in the examination report. Pityrosporum folliculitis 5. Schedule the Veteran for a VA examination to address current nature and severity of his service-connected Pityrosporum folliculitis. The claims file should be made available to and reviewed by the examiner. A complete history should be elicited, to include the types of medications that have been used/prescribed to treat his service-connected skin disability, if any, and a description of flare-ups, if any. The examiner should describe in detail all current manifestations of the Veteran’s disability, if any. The examiner must indicate the percentage of the Veteran’s body affected by the skin disabilities. The location and extent of any scarring due to the skin disabilities should also be described (and if there is none, it should be so stated). It should be noted that the Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptoms. The examiner should take as truthful, the Veteran’s competent and credible statements regarding the severity of his symptomatology. The examination report should include an account of all manifestations of the Veteran’s service-connected anxiety disability found to be present and whether those symptoms are related to the Veteran’s service-connected hypothyroidism. STEVEN D. REISS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Jacquelynn M. Jordan, Associate Counsel