Citation Nr: 1319087 Decision Date: 06/12/13 Archive Date: 06/21/13 DOCKET NO. 11-01 807 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Lincoln, Nebraska THE ISSUES 1. Entitlement to service connection for a psychiatric disorder to include posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for a heart disorder. 3. Entitlement to service connection for fibromyalgia. 4. Entitlement to service connection for a sleep disorder. 5. Entitlement to service connection for a gastrointestinal disorder, to include gastroesophageal reflux disease (GERD), acid reflux, hiatal hernia, heartburn, and irritable bowel syndrome (IBS). 6. Entitlement to service connection for residuals of cold injury to the hands. 7. Entitlement to service connection for residuals of cold injury to the feet. 8. Entitlement to service connection for bilateral tinea pedis and onychomycosis. REPRESENTATION Appellant represented by: John S. Berry, Attorney at Law ATTORNEY FOR THE BOARD C. Lawson, Counsel INTRODUCTION The appellant is a Veteran who served on active duty from January 1953 to January 1956. This matter is before the Board of Veterans' Appeals (Board) on appeal from November 2009, May 2011, and November 2011 rating decisions of the Lincoln, Nebraska Department of Veterans Affairs (VA) Regional Office (RO). A November 2009 RO rating decision denied the Veteran service connection for PTSD. He initiated an appeal of that decision, and in December 2010, the RO issued a statement of the case. In light of his subsequent statements expanding his claim to encompass other psychiatric diagnoses, and the United States Court of Appeals for Veterans Claim's (Court's) decision in Clemons v. Shinseki, 23 Vet. App. 1 (2009), the issue has been recharacterized as one of service connection for a psychiatric disorder to include PTSD. The issue of service connection for a gastrointestinal disorder encompasses IBS which has been separately addressed by the RO. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). The appeal is REMANDED to the VARO. VA will notify the appellant if further action is required on his part. REMAND Under 38 C.F.R. § 3.159 (2012), VA has a duty to assist a claimant in developing claims. Once a claimant identifies relevant treatment records, VA has a duty to assist such claimant to obtain them. VA also has a duty to assist a claimant by providing medical examinations or opinions when such are necessary to decide a claim. 38 C.F.R. § 3.159. Under McLendon v. Nicholson, 20 Vet. App. 79 (2006), in a claim seeking service connection, a VA medical examination is necessary when there is (1) competent evidence of a current disability, and (2) evidence that an event, injury, or disease occurred in service or establishing certain diseases manifested during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran's service or wither another service-connected disability, but (4) insufficient medical evidence on file for the Secretary to make a decision on the claim. The Court held that the determination as to when a VA examination/medical opinion is necessary is a "low threshold" requirement. Service personnel records show that the Veteran served in Korea and Japan, and he has submitted statements and photographs indicating/suggesting that he was exposed to cold weather while serving in those locations. The Veteran has claimed service connection for foot skin disorders and residuals of cold injuries to the feet and hands. His service treatment records (STRs) do not show complaints or treatments of hand or foot problems, and on January 1956 service discharge examination, his upper and lower extremities and skin were normal on clinical evaluation. In January 2011, he asserted that when he served in Korea, he was forced to wear damp socks for long periods of time, and that this caused his feet to constantly be damp and very cold, and that as a result of this, they began to itch all the time. To the best of his memory, since then, the skin on his feet had been scaly and hard, and his toenails had been thickened. In July 2012 a VA examiner noted that the Veteran had diagnoses of cold injury residuals of both hands and both feet. In November 2012, that same examiner referred to the problem as "claimed" cold injuries of the hands and feet. Based on the wording, it is unclear whether diagnoses of cold injuries of the hand and feet were deemed appropriate. The examiner did not opine whether or not any current residual of cold injuries of the Veteran's hands and feet are related to his exposure to cold in service. On July 2012 VA examination, arthralgia, numbness, cold sensitivity, nail abnormalities of both feet, onychomycosis, and rough, dry, scaly feet were diagnosed. Given the Veteran's acknowledged exposure to cold in service, an examination to determine whether there is a nexus between any current disability and the Veteran's exposure to cold in service is necessary. The issues of service connection for tinea pedis and onychomycosis, and cold injuries to the feet, appear intertwined at this point, as the July 2011 examiner indicated that nail abnormalities of the Veteran's feet were signs and symptoms of cold injury and noted that the Veteran had onychomycosis of his nails, and rough, dry, scaly feet. Regarding the claim of service connection for PTSD, in August 2010/January 2011, the Veteran asserted that a pilot he knew well and a passenger he had met a couple of times died in a plane crash, and that he was sent to recover the plane and secure the site. He indicated that he remembers the event to this day, has dreams about it on occasion, and has trouble getting and staying asleep. In January 2011, he submitted photographs of an airplane and a copy of a death certificate showing that a service member died in a plane crash in Japan in May 1954. Further development to corroborate his participation in such incident and whether he has PTSD as a result is necessary. The Veteran claims service connection for a heart disorder, fibromyalgia, a sleep disorder, and a gastrointestinal disorder, as secondary to a psychiatric disorder. Notably, of these claimed disorders, the only one documented in the record is heart disease. None was manifested in service. If service connection is established for a psychiatric disorder, further development of these matters would be necessary. The Veteran's service ended in January 1956 and the earliest post-service medical evidence of record is dated in 1994, many years after service. Any existing records of treatment for the claimed disorders prior to 1994 should be secured. Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). Expedited handling is requested.) 1. The RO should ask the Veteran to identify all providers of postservice treatment he has had for each of the disabilities at issue (records of which are not already associated with the claims file), and to provide releases for VA to secure records of treatment by any private providers. The RO should secure for the record the complete clinical records from all identified sources. 2. The RO should then arrange for the Veteran to be examined by an appropriate physician to ascertain the nature and likely etiology of any cold injury residuals he may have. He should be asked to identify all pathology he seeks to have service-connected as cold injury residuals. Based on a review of the entire record and interview and examination of the Veteran (and noting that he served in cold climates during winter), the examiner should provide opinions that respond to the following: (a) Please identify (by medical diagnosis) any (and each) disability entity of the Veteran's hands and feet that at least as likely as not (a 50 % or greater probability) is a residual of cold injury (this should include all pathology claimed by the Veteran). (b) As to each cold injury residual disability entity found (and specifically noting whether or not bilateral tinea pedis and/or onychomycosis are included), please opine whether such is at least as likely as not (a 50 % or greater probability) related to exposure to cold/damp weather in Korea and/or Japan. The examiner must explain the rationale for all opinions, citing to supporting factual data and medical literature, as appropriate. 3. The RO should arrange for any further stressor verification indicated (i.e., of the Veteran's participation in the recovery of a crashed airplane with acquaintances aboard) and then arrange for a psychiatric examination of the Veteran to ascertain the nature and likely etiology of any current psychiatric disorder. The RO must advise the examiner of any stressor events that are corroborated by credible evidence. The examiner must review the entire record, and based on review of the record and examination of the Veteran the examiner should provide opinions that respond to the following: (a) Please identify by medical diagnosis each psychiatric disorder found; specifically, does the Veteran have a diagnosis of PTSD. (b) As to each psychiatric disorder diagnosed, please indicated whether such is at least as likely as not (a 50 % or greater probability) related to the Veteran's service, including (if PTSD is diagnosed) whether such is related to a stressor event that RO found to be corroborated by credible supporting evidence. The examiner must explain the rationale for all opinions, citing to supporting factual data and medical literature, as appropriate. 4. If the Veteran is found to have a psychiatric disease which is service-connected, the RO should arrange for the Veteran to be examined by an appropriate physician (or physicians) to determine whether or not each disability for which secondary service connection is sought and which is shown by the record (to include heart disease and any further diagnosed entities shown by the record received pursuant to the request above) was caused or aggravated by the service-connected psychiatric disease. The entire record must be reviewed by the examiner in conjunction with the examination. The examiner must be advised by the RO of what additional disabilities claimed are shown by the record. The examiner(s) must explain the rationale for all opinions, citing to supporting factual data and medical literature, as appropriate. 5. The RO should then review the record, and readjudicate the claims. If any remains denied, the RO should issue an appropriate supplemental statement of the case and afford the Veteran and his attorney the opportunity to respond. The case should be returned to the Board. 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). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board 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). _________________________________________________ George R. Senyk 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).