Citation Nr: 1307985 Decision Date: 03/11/13 Archive Date: 03/20/13 DOCKET NO. 10-18 189A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUES 1. Entitlement to service connection for a skin disorder. 2. Entitlement to service connection for a nasal disorder. 3. Entitlement to service connection for a sleep disorder. 4. Entitlement to a higher initial evaluation for posttraumatic stress disorder (PTSD), currently evaluated as 30 percent disabling. REPRESENTATION Appellant represented by: Illinois Department of Veterans Affairs WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD C. Lawson, Counsel INTRODUCTION The Veteran served on active duty from September 1966 to September 1969. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a March 2008 rating decision by a Regional Office (RO) of the Department of Veterans Affairs (VA). A notice of disagreement was received in April 2009, a statement of the case was issued in March 2010, and a substantive appeal was received in May 2010. The Veteran presented testimony at a Board hearing before the undersigned Veterans Law Judge in March 2012, and a transcript of the hearing is associated with his claims folder. The issue of service connection for disability of the feet was raised by the Veteran in a March 2009 statement, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). It is unclear based on the March 2009 statement, but the Veteran may also be claiming service connection for erectile dysfunction. The Board does not have jurisdiction over these matters and they are referred to the AOJ for appropriate action. 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 seeks service connection for a skin disorder, a nasal disorder, and a sleep disorder, including sleep apnea and other trouble with sleeping, as well as a higher initial rating for his service-connected PTSD. The only service treatment records which are contained in the claims folder are reports of medical histories and examinations for service entrance and discharge. In the Veteran's service discharge report of medical history, he indicated that he had had ear, nose, or throat trouble which he had not reported on service entrance examination. Through October 2006, January 2007, and March 2012 statements, the Veteran has indicated that he had jungle rot on his face and in his nose in service. He has indicated that in service, he had had scabs on the side of his face, which were scrubbed off with an ointment and/or soap, and that eventually, they went away, but that every once in a while, he would get a zit or something similar to it. He indicated that he has a scar on his face from the jungle rot. He indicated that Dr. Coleman has been treating him for his skin condition. He also indicated that he had had nosebleeds in service, and that to treat them, they sent him to Da Nang hospital and operated on his nose, removing a growth that may have been benign or infected. Ever since then, he would get a tingle and itch, and it would bleed, including when he sneezed sometimes. Also, at times, he has a problem breathing. He indicated that he has been diagnosed with a sleep disorder and/or sleep apnea, and takes Ambien, and that Sedgwick Coleman, M.D. had told him that because of the in-service surgery to his nose and the deviated septum, his breathing problems and sleep apnea were due to service. He also testified that in the course of treatment he has received, a Dr. Gallo has treated him for his psychiatric problems with relaxation techniques, deep breathing, and soothing music, and that he sees him every 2 weeks. As noted above, only entrance and discharge examination reports are of record. It is possible that additional service treatment records, including from the Da Nang hospital are obtainable. The Board also notes that a service personnel record contains mention of the 86th Evac Hospital at Fort Campbell in 1968. Accordingly, action to obtain any such available records should be performed in order to assist the Veteran in accordance with 38 C.F.R. § 3.159 (2012). Next, the most recent records from Dr. Coleman which are contained in the claims folder are dated in December 2007, and none of them contain the above information which the Veteran indicates Dr. Coleman had told him. It may be that more recent records contain this information. The only information from Dr. Gallo is a March 2008 treatment summary. Records were last requested from Drs. Coleman and Gallo in December 2006, more than 6 years ago. In light of the above, additional record development from these doctors will be performed, in order to assist the Veteran in accordance with 38 C.F.R. § 3.159. Moreover, additional VA examinations will be ordered to assist the Veteran in light of 38 C.F.R. § 3.159. In light of the evidence of record and that which may be forthcoming as a result of records development, VA examinations will be ordered for the Veteran's claims for service connection for sleep disorder, skin disorder, and nasal disorder, as indicated below. Moreover, the most recent and only VA psychiatric examination was in March 2008, roughly 5 years ago, and the Veteran argues that his PTSD is worse than 30 percent disabling. In light of the above, another VA psychiatric examination will be obtained. As the Veteran appears to be claiming sleep and breathing disorders which are or may be secondary to his service-connected PTSD or secondary to a nasal disorder which he is claiming, he should be provided with VCAA secondary service connection notice and development. Accordingly, the case is REMANDED for the following action: 1. Provide the Veteran with VCAA secondary service connection notice and development. 2. Make arrangements to obtain any additional available service treatment records, including the records of treatment the Veteran received at the Da Nang hospital during service, to include asking the NPRC to search for any separately stored hospital inpatient records. The NPRC should also be requested to search for any inpatient records from the 86th Evac Hospital at Fort Campbell in 1968. Also, obtain all actual clinical records of treatment which the Veteran has received from Dr. Gallo since the October 2006 date of claim; and all clinical records of treatment he has received from Dr. Coleman since December 2007. 3. After records development has been completed, the Veteran should be scheduled for an appropriate VA examination with regard to his skin, nasal, and sleep disorder claims. It is imperative that the claims file, to include a copy of this remand, be made available to the examiner for review in connection with the examination. Any current skin, nose, or sleep disorders should be clearly reported. After reviewing the claims file and examining the Veteran, the examiner should attempt to summarize what skin and/or nasal procedures and diagnoses occurred during service, and respond to the following: a) Is it at least as likely as not (a 50% or higher degree of probability) that any current nose, skin, or sleep disorder (including any current nose bleeds, facial scar, or sleep apnea) is causally related to any disease, injury, or event of service? b) Is it at least as likely as not (a 50% or higher degree of probability) that any current sleep disorder is proximately due to or caused by the Veteran's service-connected PTSD or by a nasal disorder which is related to service? c) Is it at least as likely as not (a 50% or higher degree of probability) that any current sleep disorder has been aggravated by the Veteran's service-connected PTSD or by a nasal disorder which is related to service? In formulating the above opinions, the examiner should consider all available service treatment records; that the Veteran had ear, nose, or throat trouble in service; the information of record which the Veteran has provided concerning in-service skin and nose trouble; and any information concerning service symptoms which the Veteran furnishes the examiner at the time of the examination. The examiner should furnish reasons for the opinions. 4. The Veteran should be scheduled for a VA psychiatric examination to determine the current severity of his service-connected PTSD and the symptoms caused by it. It is imperative that the claims file, to include a copy of this remand, be made available to the examiner for review in connection with the examination. Following examination of the Veteran, the examiner should identify what symptoms, if any, the Veteran currently manifests or has manifested in the recent past that are attributable to his service-connected PTSD. The examiner must conduct a detailed mental status examination. All information necessary to rate the Veteran's PTSD under 38 C.F.R. § 4.130's General Rating Formula for Mental Disorders should be provided. The examiner must discuss the effect, if any, of the Veteran's PTSD on his social and industrial adaptability. The examiner should assign a Global Assessment of Functioning (GAF) score for the Veteran's PTSD consistent with the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM- IV) and explain the significance of the score. A complete rationale for all opinions should be provided. 5. Thereafter, readjudicate the Veteran's pending claims in light of any additional evidence added to the record. If the benefits sought on appeal remain denied, the Veteran and his representative should be furnished a supplemental statement of the case and given the opportunity 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. 2012). _________________________________________________ MICHAEL MARTIN 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) (2012).