Citation Nr: 0811479 Decision Date: 04/08/08 Archive Date: 04/23/08 DOCKET NO. 03-22 321 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Entitlement to an initial rating in excess of 30 percent for post-traumatic stress disorder (PTSD). 2. Whether new and material evidence has been received to reopen a claim for service connection for a left knee disability. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD M. Scott Walker, Associate Counsel INTRODUCTION The veteran served on active duty from February 1966 to November 1967. This matter comes before the Board of Veterans' Appeals (Board) on appeal from March 2003 and September 2004 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio. The veteran was afforded a Board hearing, presided over by the undersigned, in February 2008. The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if further action is required. REMAND The veteran was granted service connection for PTSD, with a 30 percent disability rating, in March 2003. The veteran's most recent VA examination was afforded in April 2005. During the veteran's February 2008 Board hearing, he testified that his service-connected PTSD symptoms were worsening. According to the veteran, he has been experiencing symptoms such as depression, panic attacks, sleep disorders, and memory loss. He also stated that his medications have been adjusted. Pursuant to VA's duty to assist, VA will provide a medical examination or obtain a medical opinion based upon a review of the evidence of record if VA determines it is necessary to decide the claim. 38 C.F.R. § 3.159(c)(4)(i) (2007). Because the veteran has asserted that his service-connected disability has worsened since his last examination, he should be afforded another VA evaluation, in accordance with VA's duty to assist, in order to determine the nature and extent of his service-connected PTSD. See Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994); VAOPGCPREC 11-95 (1995). The examiner should indicate a complete review of the veteran's claims file. Moreover, the veteran testified that he is currently receiving VA treatment for his PTSD. The Board also notes that, when reference is made to pertinent medical records, VA is on notice of their existence and has a duty to assist the veteran to attempt to obtain them. See Ivey v. Derwinski, 2 Vet. App. 320, 323 (1992); see also Jolley v. Derwinski, 1, Vet. App. 37 (1990). Therefore, the RO should obtain the veteran's VA treatment records, from the Cleveland VAMC, from 2006 to the present. Further, during the veteran's February 2008 hearing, his representative stated that a VA progress note dated September 2, 2005, provided a positive nexus opinion regarding the veteran's left knee condition. However, the Board has been unable to locate any such record within the veteran's claims file. On remand, the RO should obtain a copy of the VA progress note in question, if available. If this record does not exist or is otherwise unavailable, that should be noted and associated with the veteran's claims file. Any other indicated development should also be undertaken. Accordingly, the case is REMANDED for the following actions: 1. The RO/AMC should take appropriate steps to obtain the veteran's Cleveland VAMC treatment records from 2006 to the present. If any records are unavailable, that information should be noted and associated with the veteran's claims file. 2. After receiving the above medical records, to the extent available, schedule the veteran for a VA psychiatric examination to determine the current level of severity of his service- connected PTSD. The claims folder must be made available to the examiner for review before the examination. Detailed clinical findings should be reported in connection with the evaluation. The examiner should report a full multiaxial diagnosis, to include the assignment of a global assessment of functioning (GAF) score consistent with the American Psychiatric Association's Diagnostic and Statistical Manual for Mental Disorders (DSM-IV) and an explanation as to what the assigned score represents. In addition, the examiner should state an opinion as to the degree of occupational and social impairment caused by the veteran's service-connected PTSD. 3. The RO/AMC should also take appropriate steps to obtain the VA progress note to which the veteran's representative referred during the veteran's February 2008 Board video hearing, dated September 2, 2005 (presumably from the Cleveland VAMC). If this record is unavailable, that information should be noted and associated with the veteran's claims file. Upon receipt of that record, the RO/AMC should undertake any other indicated development, if appropriate, to include obtaining a medical opinion in this case on the left knee issue if deemed necessary. 4. The AMC should then readjudicate the claims on appeal in light of all of the evidence of record. If the issues remain denied, the veteran should be provided with a supplemental statement of the case as to the issues on appeal, and afforded a reasonable period of time within which to respond thereto. 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 Supp. 2006). _________________________________________________ S. L. Kennedy Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2007).