Citation Nr: 1319574 Decision Date: 06/18/13 Archive Date: 06/27/13 DOCKET NO. 09-50 307 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for subacute peripheral neuropathy of the upper and lower extremities. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Rebecca Feinberg, Counsel INTRODUCTION The Veteran had active service from October 1965 to October 1969. This matter comes to the Board of Veterans' Appeals (Board) on appeal from an April 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The Board notes that the issue of entitlement to service connection for a psychiatric disorder was initially adjudicated as entitlement to service connection for PTSD. However, the United States Court of Appeals for Veterans Claims (Court) has held that claims for service connection for PTSD encompass claims for service connection for all psychiatric disabilities. Clemons v. Shinseki, 23 Vet. App 1 (2009). Therefore, the Board has recharacterized the issue on appeal as reflected on the title to page to ensure that all diagnoses are considered in the adjudication of the claim. A review of the Veteran's virtual VA claims file indicates that all evidence contained therein is duplicative of evidence already contained in the paper claims file or irrelevant to the issues on appeal. 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 Board finds that further development is necessary prior to final adjudication of the claims on appeal. During the course of the appeal, the Veteran has indicated that he received VA treatment at the VA Medical Center in Cleveland, Ohio, in the 1970s; the VA Medical Center in Dayton, Ohio, in the 1970s and 1980s; and, the VA outpatient clinic in Daytona Beach, Florida from 1986 to the present. Various other records in the claims file suggest that the Veteran also sought and received treatment at the VA Medical Center in Cincinnati, Ohio, in the 1980s. However, the only VA treatment records contained in the claims file are from the VA outpatient clinic in Daytona Beach, Florida, and they are dated in November 2008 and December 2008 only. There is no indication that any of the other VA records identified by the Veteran were requested. Therefore, an attempt should be made to obtain any outstanding VA medical records. With regard to the Veteran's claim of entitlement to service connection for a psychiatric disorder, the Board also finds that a remand for a VA examination and medical opinion is necessary. The Veteran has submitted several stressor statements alleging that he as subjected to mortars, grenades, automatic weapons, and small arms fire nearly every day while serving in Vietnam. He also described a particular incident when he was almost killed by automatic gunfire. The Veteran's service personnel records do show that he had service in Vietnam from June 1967 to July 1968. His principal duty while there was as a military policeman. Additionally, a November 2008 VA outpatient treatment record shows that the Veteran's PTSD screen was positive, and he has been diagnosed with PTSD and depression. He has complained of nightmares, anger, anxiety, sadness, jumpiness, and trouble sleeping. The Veteran's reported stressor appears to involve the threat of hostile military or terrorist activity and is consistent with the nature and circumstances of his service. 38 C.F.R. § 3.304(f). While there is a diagnosis of PTSD of record that was provided by a VA physician, it is based upon a general report that the Veteran served in Vietnam. There was no discussion of any of the Veteran's reported stressors. Therefore, the Board finds that a VA examination and medical opinion are necessary to determine the nature and etiology of any psychiatric disorder that may be present. Accordingly, the case is REMANDED for the following action: 1. The RO/AMC should obtain any outstanding treatment records from the VA Medical Centers in Cleveland, Ohio; Dayton, Ohio, and Cincinnati, Ohio, as well as the outpatient clinic in Daytona Beach, Florida, that are not already associated with the claims file. In particular, the records from the Ohio facilities should be requested beginning in the 1970s. The Veteran indicated that he began receiving treatment at the Daytona Beach clinic in 1986. All attempts to secure these records, and any response received, must be documented in the claims file. If any records are not available, a response to that effect is required and should be documented in the file. 2. The RO/AMC should schedule the Veteran for a VA psychiatric examination. The claims folder must be available for review by the examiner. Additionally, all relevant medical records must be made available to the examiner for review, either in the Virtual VA eFolder, or if the eFolder is not available, then via paper copies. If the Veteran is diagnosed with PTSD, the examiner is requested to state: (1) whether the diagnosis is at least as likely as not related to the Veteran's report of having receiving incoming fire while service as a military policeman in Vietnam; and (2) whether this reported in-service stressor is adequate to support the diagnosis of PTSD. If so, he or she should state whether it is at least as likely as not that the Veteran's current psychiatric symptoms are related to the claimed in-service stressors. If the Veteran is diagnosed with an acquired psychiatric disorder other than PTSD, the examiner is requested to opine whether it is at least as likely as not that the disorder is related to his active military service or events therein. A complete rationale for any opinions expressed must be provided. 3. The RO/AMC should then review the claims file and ensure that all of the foregoing development actions have been conducted and completed in full. If any development is incomplete, appropriate corrective action should be implemented. If any report does not include adequate responses to the specific opinions requested, it should be returned to the examiner for corrective action. See Stegall v. West, 11 Vet. App. 268, 271 (1998). 4. When the development requested has been completed, the case should be reviewed by the RO/AMC on the basis of additional evidence. If the benefits sought are not granted, the Veteran and his representative should be furnished a Supplemental Statement of the Case and be afforded a reasonable opportunity to respond before the record is returned to the Board for further review. 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). _________________________________________________ JESSICA J. WILLS 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).