Citation Nr: 1129503 Decision Date: 08/10/11 Archive Date: 08/23/11 DOCKET NO. 08-18 475 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUE Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD D. M. Donahue, Associate Counsel INTRODUCTION The Veteran served on active duty from March 1969 to March 1971. He was awarded the Combat Infantryman's Badge and Vietnam Service Medal. This case initially came before the Board of Veterans' Appeals (Board) on appeal from a July 2007 rating decision. A videoconference hearing was held in March 2011, before the undersigned Acting Veteran's Law Judge. A transcript of the hearing testimony is in the claims file. 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 Veterans Claims Assistance Act of 2000 specifically provides that the duty to assist includes providing a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on the claim. 38 U.S.C.A. § 5103A(d). The Veteran was afforded fee-based psychiatric examinations in June 2007 and April 2010. The June 2007 fee-based examination report indicates that the diagnosis was PTSD. The examiner indicated that the Global Assessment of Functioning (GAF) score was 80. The April 2010 examiner also gave a diagnosis of PTSD and assigned a GAF score of 70. The April 2010 examiner opined that the Veteran had mild PTSD symptoms with occasional moderate social and occupational dysfunction. During his March 2011 Board hearing, the Veteran asserted that his most recent April 2010 fee-based examination was inadequate as he was sick at the time and he did not feel he was able to convey his symptoms accurately. He claimed he experienced anxiety attacks related to his nightmares, and that two months prior he was prescribed medication for anxiety and sleep problems. VA is required to conduct an accurate and descriptive medical examination based on the complete medical record. 38 C.F.R. §§ 4.1, 4.2; Green v. Derwinski, 1 Vet. App. 121, 124 (1991) (VA's duty to assist includes "the conduct of a thorough and contemporaneous medical examination, one which takes into account the records of prior medical treatment, so that the evaluation of the claimed disability will be a fully informed one"). In light of the evidence showing that the Veteran's PTSD may not have been accurately assessed at the most recent VA examination due to the Veteran's illness, another VA examination is warranted to determine the current severity of the Veteran's service-connected PTSD. The RO should also obtain all records of the Veteran's treatment for the PTSD from the VA healthcare system in Virginia dated from March 2010. VA has a duty to seek these records. 38 U.S.C.A. § 5103A(b)(1). Accordingly, the case is REMANDED for the following action: 1. The RO should take appropriate steps to contact the Veteran in order to have him provided detailed information concerning all treatment he has received for his service-connected PTSD. Based on his response, the RO should attempt to obtain the outstanding records from any identified treatment source. 2. The RO should obtain all records of the Veteran's treatment for the PTSD from the VA healthcare system in Virginia dated from March 2010 to the present. 3. The RO should afford the Veteran a VA psychiatric examination to evaluate the current severity of the PTSD. The Veteran's VA claims folder must be made available to the examiner for review in connection with the examination. All indicated tests and studies should be performed. The examiner should identify all symptoms and functional impairment due to the PTSD and provide a global assessment of functioning (GAF) score based on the Veteran's service-connected PTSD. The examiner should indicate whether the PTSD causes: occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal, due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks, chronic sleep impairment, and mild memory loss; or occupational and social impairment with reduced reliability and productivity, impairment of short- and long-term memory, impaired judgment, impaired abstract thinking, disturbances of motivation and mood, or difficulty in establishing effective work and social relationships; or occupational and social impairment, with deficiencies in most areas, including work, school, family relations, judgment, thinking, or mood; or total occupational and social impairment. Any opinions expressed by the examiner must be accompanied by a complete rationale. 4. Following completion of all indicated development, the RO should readjudicate the issue on appeal in light of all the evidence of record. If the benefit sought on appeal remains denied, the Veteran and his representative should be furnished a Supplemental Statement of the Case and afforded the requisite opportunity to respond thereto. Thereafter, if indicated, the case should be returned to the Board for the purpose of appellate disposition. 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. 2010). _________________________________________________ C. L. KRASINSKI 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) (2010).