Citation Nr: 18151237 Decision Date: 11/16/18 Archive Date: 11/16/18 DOCKET NO. 16-46 174 DATE: November 16, 2018 REMANDED Entitlement to a rating in excess of 50 percent for HIV related illness with chronic dysthymia is remanded. REASONS FOR REMAND The Veteran served on active duty from July 1991 through July 1996. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2012 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran’s representative alleges that the Veteran has sleep apnea secondary to his HIV related illness. See June 2018 Correspondence. This claim has a separate appeals stream which has not yet been certified to the Board. Consequently, the Board does not have jurisdiction over the Veteran’s claim for secondary service connection for sleep apnea and it will not be addressed in this decision. The Veteran was last afforded a VA examination for his HIV in August 2011. Since that examination, the record reflects that additional symptoms may have manifested. Although the Veteran began antiretroviral treatment in 2012, he continued to report symptoms of chest pain and left thumb and left wrist pain with no noted etiology in December 2012. See August 2016 CAPRI at 82. In April 2013, the Veteran reported small non-pruritic nonpainful pink to red papules on left shoulder over the clavicular area for a few months and complained of some dry skin over his hand and around his mouth over the past several months despite aggressive cream use. See August 2016 CAPRI at 79. In May 2013, the Veteran endorsed symptoms of sleep difficulties, ongoing feelings of being unwell, exhaustion and little or no social life. In September 2014, the Veteran reported a reoccurring nodule on his left temple. See August 2016 CAPRI at 70. In May 2015 the Veteran endorsed symptoms of worsening memory, difficulty following along in meetings, difficulty recalling the content of the issues discussed during meetings, and difficulty expressing himself verbally in meetings. The Veteran attended an initial intake and treatment session for mental health in July 2015. The Veteran scored a 22 on the PHQ-9, which is indicative of a severe level of depressive symptoms. See August 2016 CAPRI at 20, 21. The Veteran underwent a neuropsychological evaluation in June 2015. Relative cognitive weakness/deficits were observed in verbal and nonverbal learning and recall, psychomotor processing speed, aspects of executive functioning and visual-spatial construction. Further, the Veteran’s performance on timed tasks was below expectation, suggesting slow processing of novel information. He also tended to display greater difficulty on tasks with increased demands for organization and effortful processing. See August 2016 CAPRI at 36, 37. At a July 2016 HIV follow up examination, the Veteran’s HIV was noted to be stable on Dolutegravir and Truvada. The Veteran endorsed symptoms of numbness of both forearms that awakens him from his sleep, which he reported had been ongoing for about a year. The doctor opined that the Veterans symptoms could be related to his HIV medications but did not offer a definitive etiology. See August 2016 CAPRI at 2. In November 2016, the Veteran reported bilateral arm and forearm numbness, that occur only at night and wake him from sleep and lasts for a few minutes, resolved by shaking his arm. He also reported on and off itching of the forearms, but had no rash. The Veteran was diagnosed with parasthesia of the bilateral upper extremities of unclear etiology. See April 2017 CAPRI at 33. The Veteran also endorsed symptoms of multiple bowel movements with polyuria, six to seven soft tomato paste like stools daily and dry mouth due to his psychiatric medications. See April 2017 CAPRI at 35. The Veteran continued to report cognitive impairment in December 2016. None of the aforementioned symptoms have been definitively excluded as related to the Veteran’s diagnosis of HIV. The Veteran’s HIV related illness is currently rated under diagnostic code 6351-9433. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.29. Diagnostic Code 6351 pertains to HIV related illnesses. Note 2 to of the diagnostic code provides that psychiatric or central nervous system manifestations, opportunistic infections, and neoplasms may be rated separately under appropriate codes if higher overall evaluation results, but not in combination with percentages otherwise assigned above. Diagnostic Code 9433 pertains to persistent depressive disorder (dysthymia). Ratings are based on the severity of the Veteran’s occupational and social impairment as a result of psychological symptoms and include consideration of 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; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Based on the aforementioned evidence and the criteria for the applicable diagnostic codes, the Board finds that a new VA examination is warranted to establish the current severity of the Veteran’s symptoms. Moreover, the record contains no evidence of treatment since December 2016. As the record shows the Veteran has received his treatment primarily through VA, updated treatment records should be obtained. The matters are REMANDED for the following action: 1. Obtain all updated treatment records from December 2016 to present. 2. Thereafter, schedule the Veteran for a VA examination. The examiner should assess the Veteran’s occupational and social impairments as a result of his HIV and HIV related chronic dysthymia. All symptomatology associated with his HIV should be noted. In making an assessment, the examiner should opine whether the Veteran’s allegations of decreased memory, decreased social interaction, fatigue, dry skin, dry mouth, numbness, arm and wrist pain, and frequent soft bowel movements are attributable to the Veteran’s HIV or HIV related illness including dysthymic disorder. If these symptoms are attributable to the Veteran’s HIV related illness with dysthymia the examiner should opine the severity of these symptoms. (Continued on the next page)   The examiner should also note, and opine the severity of any opportunistic infections, secondary diseases afflicting multiple body systems, HIV related illness with debility and progressive weight loss without remission. S. HENEKS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Wimbish, Associate Counsel