Citation Nr: 1002158 Decision Date: 01/13/10 Archive Date: 01/22/10 DOCKET NO. 08-23 631 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to service connection for degenerative disc disease of the cervical spine. 2. Entitlement to service connection for posttraumatic stress disorder (PTSD). 3. Entitlement to service connection for degenerative joint disease of the right shoulder. 4. Entitlement to service connection for skin disorder, claimed as a rash/hives. REPRESENTATION Veteran represented by: Virginia Department of Veterans Services WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD J. W. Kim, Counsel INTRODUCTION The Veteran had active service from April 1974 to April 1978. These matters come before the Board of Veterans' Appeals (Board) on appeal from a July 2007 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia. In May 2008, the Veteran testified during a hearing before a Decision Review Officer at the RO; a transcript of that hearing is of record. Although the Veteran filed a notice of disagreement to the denials of non service-connected pension benefits and service connection for neuropathy of the right hand, he stated that he wished to withdraw these issues during the above hearing. He submitted a written statement to that effect at that time. Thus, those issues are no longer before the Board. The appeal is REMANDED to the RO via the Appeals Management Center (AMC) in Washington, DC. VA will notify the Veteran if further action is required. REMAND Initially, in November 2009 correspondence, the Veteran requested that VA obtain updated medical records from the Lynchburg Community Based Outpatient Clinic (CBOC) before making a decision on his case. Of record are VA treatment notes from the Lynchburg CBOC dated through April 2009. The Board emphasizes that records generated by VA facilities that may have an impact on the adjudication of a claim are considered constructively in the possession of VA adjudicators during the consideration of a claim, regardless of whether those records are physically on file. See Dunn v. West, 11 Vet. App. 462, 466-67 (1998); Bell v. Derwinski, 2 Vet. App. 611, 613 (1992). Thus, the RO must obtain all pertinent medical records from the above facility since May 2009, following the procedures prescribed in 38 C.F.R. § 3.159(c) (2009). Specific to the claim for service connection for PTSD, the record contains various diagnoses of PTSD, a mood disorder, and depression. Also of record is a confirmed in-service stressor event, that of being bitten by a German Shepherd in December 1976. Although the Veteran testified that this stressor is not the main stressor, the Board finds that a VA examination with opinion is needed to determine whether he has PTSD and, if so, whether it is due to the confirmed dog attack. The Board would be remiss if it did not point out that VA treatment notes reflect that the Veteran lives with his Doberman Pinscher. As regards the claim for service connection for a skin disorder, the service treatment records clearly show that the Veteran had a skin disorder in service and post-service medical records indicate that he may still have a skin disorder. A December 2005 VA treatment note reflects complaints of a scaly, itchy rash on the right distal lower extremity that started about two weeks ago and a diagnosis of a rash. The plan was to try clotrimazole. A January 2006 VA treatment note reflects a history of urticaria. The Veteran was afforded a VA examination in April 2007. After examining the Veteran, which revealed no rash, the examiner did not provide a diagnosis or an opinion on the etiology of the claimed skin disorder. Although VA treatment notes since 2007 reflect no complaints of a rash/hives, they do reflect that the Veteran was taking loratadine and flunisolide, which the Board observes may minimize or prevent the occurrence of a rash/hives. Further, the Veteran testified during the May 2008 hearing that he still has breakouts. In this regard, the Board observes that he is competent, as a layperson, to report that about which he has personal knowledge. See Layno v. Brown, 6 Vet. App. 465, 470 (1994); Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). Based on the above, the Board concludes a new VA skin examination is warranted. If feasible, the Veteran should be examined while his skin disorder is exhibiting observable symptomatology. See Ardison v. Brown, 6 Vet. App. 405, 408 (1994) (indicating that, to the extent possible, VA should schedule an examination for a condition that has cyclical manifestations during an active stage of the disease to best determine its severity); see also Bowers v. Derwinski, 2 Vet. App. 675, 676 (1992) (holding that "it is the frequency and duration of the outbreaks and the appearance and virulence of them during the outbreaks that must be addressed."). Lastly, a February 2006 VA treatment note reflects that the Veteran applied for Social Security Disability benefits. While records from the Social Security Administration (SSA) are not controlling for VA determinations, they may be "pertinent" to VA claims. See Collier v. Derwinski, 1 Vet. App. 412 (1991); Murincsak v. Derwinski, 2 Vet. App. 363 (1992). When VA is put on notice of the existence of SSA records, as here, it must seek to obtain those records before proceeding with the appeal. Thus, the RO should obtain and associate with the claims file copies of any SSA disability determination and all medical records underlying any such determination, following the procedures prescribed in 38 C.F.R. § 3.159(c). Accordingly, the case is REMANDED for the following actions: 1. The RO should obtain all pertinent records of treatment for the Veteran since April 2009 from the VA Lynchburg CBOC, following the procedures prescribed in 38 C.F.R. § 3.159(c). 2. The RO should request from SSA copies of any decision(s) and medical records submitted or obtained in support of any claim for disability benefits. If the records are unavailable, SSA should so indicate. If unsuccessful, the Veteran and his representative should be accorded the opportunity to furnish such records directly to VA. All records/responses received should be associated with the claims file. 3. The RO should schedule the Veteran for a VA psychiatric examination to determine the current nature and etiology of any psychiatric disorder found to be present; and to determine if the Veteran meets the diagnostic criteria for PTSD and, if so, whether such is linked to a verified stressor. The examiner is to be informed of the verified in-service stressor of being bitten by a German Shepherd in December 1976 and be forwarded the claims file in its entirety for review in connection with the examination. The examination report is to contain a notation that the examiner reviewed the claims folder. The psychiatric examination is to include a review of the Veteran's history and a comprehensive mental status evaluation and tests deemed as necessary. The examiner should be asked to offer an opinion addressing the following questions: Does the Veteran meet the DSM-IV criteria for a diagnosis of PTSD? If so, is it at least as likely as not (50 percent or greater probability) that the PTSD is causally linked to the verified in-service stressor? The examiner is to be instructed that only the verified stressor may be considered for purposes of this opinion. The examiner is asked to provide the rationale used in formulating his or her opinion in the written report. 4. The RO should schedule the Veteran for a VA skin examination to determine the current nature and etiology of any skin disorder found to be present. The examiner is to be forwarded the claims file in its entirety for review in connection with the examination. The examination report is to contain a notation that the examiner reviewed the claims folder. The skin examination is to include a review of the Veteran's history and a comprehensive skin evaluation and tests deemed as necessary. The examiner should be asked to offer an opinion addressing the following question: Is it at least as likely as not (50 percent or greater probability) that the Veteran's existing or previously existing rash/hives had its onset in service or is otherwise related to service? The examiner is asked to provide the rationale used in formulating his or her opinion in the written report. 5. Thereafter, the RO should readjudicate the claims. If any benefit sought on appeal remains denied, the Veteran and his representative should be provided a supplemental statement of the case and given an opportunity to respond. The appellant 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.A. §§ 5109B, 7112 (West Supp. 2009). _________________________________________________ S. BUSH Acting 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) (2009).