Citation Nr: 1325748 Decision Date: 08/14/13 Archive Date: 08/16/13 DOCKET NO. 10-04 674 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New Orleans, Louisiana THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), anxiety, and depression. 2. Entitlement to service connection for hypertension, to include as a result of exposure to herbicide and/or secondary to service-connected diabetes mellitus and/or currently non-service-connected acquired psychiatric disorder. REPRESENTATION Veteran represented by: Veterans of Foreign Wars of the United States WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD J.N. Moats, Counsel INTRODUCTION The Veteran served on active duty from March 1968 to February 1970. The issue of entitlement to service connection for hypertension comes before the Board of Veterans' Appeals (Board) on appeal from a December 2008 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in New Orleans, Louisiana. The issue of entitlement to service connection for an acquired psychiatric disorder comes before the Board on appeal from a May 2009 rating decision. The Veteran and his spouse testified before the undersigned Veterans Law Judge sitting at the RO in August 2012. A transcript of the hearing is associated with the claims file. The Board remanded this case for additional development in December 2012 and it now returns for further appellate review. The Virtual VA paperless claims processing system contains a substantial number of additional VA records of outpatient treatment dated from August 2010 to December 2012 that were considered by the agency of original jurisdiction (AOJ) in a supplemental statement of the case (SSOC) issued in February 2013. Additional VA examination reports were associated with the claims file after the most recent February 2013 SSOC. However, as these examinations do not address the issues on appeal, they are not pertinent to the claims and in turn, waiver of AOJ consideration of this evidence is not necessary. 38 C.F.R. § 20.1304(c) (2012). The issue of entitlement to service connection for an acquired psychiatric disorder is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, D.C. FINDING OF FACT For the entire appeal period, the evidence fails to show that the Veteran has a current diagnosis of hypertension for VA purposes. CONCLUSION OF LAW The criteria for service connection for hypertension have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION Veterans Claims Assistance Act of 2000 As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In addition, the notice requirements of the VCAA apply to all elements of a service-connection claim, including: (1) Veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. VCAA notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as a statement of the case or supplemental statement of the case, is sufficient to cure a timing defect). With respect to the issue being decided herein, the Veteran was sent an October 2008 letter that fully addressed all notice elements and was sent prior to the initial RO decision in this matter. The letter provided information as to what evidence was required to substantiate the claim and of the division of responsibilities between VA and a claimant in developing an appeal. Moreover, the letter informed the Veteran of what type of information and evidence was needed to establish a disability rating and effective date. An additional VCAA notice addressing the information and evidence needed to substantiate the issue of service connection for hypertension under a secondary theory of entitlement was sent to the Veteran in December 2012. The Board recognizes that this notice was provided after the initial decision. However, the deficiency in the timing of this notice was remedied by readjudication of the issue on appeal in the February 2013 SSOC. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Accordingly, no further development is required with respect to the duty to notify. Next, VA has a duty to assist the Veteran in the development of the claims. This duty includes assisting him in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). The claims file contains the Veteran's service treatment records, as well as post-service reports of private and VA treatment and VA examination report. As noted above, a review of the Virtual VA paperless claims processing system includes additional VA treatment records that were considered in the most recent SSOC issued in February 2013. Moreover, the Veteran's statements in support of the claim are of record, including testimony provided at the August 2012 Board hearing. The Board has carefully reviewed such statements and concludes that no available outstanding evidence has been identified. The Board has also perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claim. The Veteran was afforded a VA examination in January 2013. As the examination was conducted by a competent clinician who considered the Veteran's claims file and medical history in the report and provided an etiological opinion, complete with rationale, the Board finds that the examination and opinion is adequate to adjudicate the Veteran's claim. See Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007); Ardison v. Brown, 6 Vet. App. 405, 407 (1994); Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). For the above reasons, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Additionally, in August 2012, the Veteran was provided an opportunity to set forth his contentions during a hearing before a Veterans Law Judge. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires that the DRO or Veterans Law Judge who chairs a hearing to fulfill two duties: (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the August 2012, the Veterans Law Judge noted that the issue of service connection for hypertension was on appeal, discussed the elements necessary to substantiate the claim, and suggested evidence that may support this claim, including evidence that the Veteran might submit that may have been overlooked. Specifically, the Veteran offered hearing testimony that his hypertension was secondary to his service-connected diabetes mellitus, type II. Therefore, not only were the issues "explained . . . in terms of the scope of the claim for benefits," but "the outstanding issues material to substantiating the claim," were also fully explained. See Bryant, 23 Vet. App. at 497. Moreover, the hearing discussion indicated that additional VA treatment records may be available and the Board remanded this case in December 2012 so that these records could be obtained. No other outstanding records were identified. To the extent any such notice may have been inadequate, this was effectively cured both by actual knowledge as evidence by statements and questions of the Veteran's authorized representative at the hearing, as well as by the Board providing such explanation of issues and suggesting submission of evidence in the subsequent remand the Board issued to develop this claim. As such, the Board finds that, consistent with Bryant, the Veterans Law Judge complied with the duties set forth in 38 C.F.R. § 3.103(c)(2) and that the Board may proceed to adjudicate the claim based on the current record. Finally, the Board finds that with respect to the hypertension issue decided herein, there was substantial compliance with the December 2012 Board remand directives. A remand by the Board confers upon the claimant, as a matter of law, the right to compliance with the remand order. Stegall v. West, 11 Vet. App. 268 (1998). Nonetheless, it is only substantial compliance, rather than strict compliance, with the terms of a remand that is required. See D'Aries v. Peake, 22 Vet. App. 97, 104 (2008) (finding substantial compliance where an opinion was provided by a neurologist as opposed to an internal medicine specialist requested by the Board); Dyment v. West, 13 Vet. App. 141 (1999). In pertinent part, the Board in December 2012 directed the AOJ to send VCAA notice informing the Veteran of the evidence and information necessary to substantiate a claim for hypertension under a secondary theory of entitlement as well as obtain VA treatment records dated from 1970, from 1990 to March 2008 and from August 2012 to the present. Thereafter, the Veteran was to be afforded a VA examination to address the etiology of any hypertension. As noted above, additional VCAA notice was sent to the Veteran in December 2012. Moreover, additional VA treatment records were associated with the Veteran's Virtual VA record. The Board recognizes that the RO did not obtain additional treatment records from 1970 and from March 1990 to March 2008 as directed in its remand. However, as discussed in more detail below, the Board has determined herein that the competent medical evidence of record shows that the Veteran does not currently suffer from hypertension and has not suffered from hypertension at any point since the filing of his March 2008 claim for service connection. As such, in light of there being no showing of a current chronic disability during the course of the appeal, VA treatment records dated from prior to this period cannot demonstrate a current disability during the relevant time period. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Accordingly, these records are not relevant to the issue of service connection for hypertension. Again, as noted above, the Veteran was also afforded a VA examination in January 2013, which as discussed in more detail below, found that the Veteran did not have a diagnosis of hypertension. Accordingly, the Board finds that there has been substantial compliance with the December 2012 Board remand directives and, therefore, no further remand is necessary. See Stegall v. West, 11 Vet. App. 268 (1998); D'Aries, 22 Vet. App. at 104 (2008). Analysis The Veteran is seeking service connection for hypertension. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. 38 U.S.C.A. § 1112; 38 C.F.R. § 3.304. See also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996) [(table)]. Additionally, for Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, such as hypertension, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Alternatively, when a disease at 38 C.F.R. § 3.309(a) is not shown to be chronic during service or the one year presumptive period, service connection may also be established by showing continuity of symptomatology after service. See 38 C.F.R. § 3.303(b). However, the use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309(a) and does not apply to other disabilities which might be considered chronic from a medical standpoint. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). In this case, service treatment records are silent for any symptoms, diagnoses, or treatment of high blood pressure or hypertension. Significantly, the Veteran's February 1970 service examination prior to discharge showed a blood pressure reading of 118/76 and was silent with respect to any findings of hypertension. In his contemporaneous medical history, the Veteran expressly denied any history of high blood pressure. The earliest post-service treatment records in the file are records of private care in January 2004. The Veteran sought treatment for respiratory distress. The attending physician noted that the Veteran had a family history of hypertension and entered a diagnosis of hypertension without explanation. Blood pressure measurements were normal with no use of appropriate medications. Private clinicians carried this diagnosis forward through January 2011. In his March 2008 claim, the Veteran noted that his hypertension began in 2007 when it was diagnosed by his private physician. When first seeking VA medical care in March 2008, a clinician noted a single high blood pressure measurement of 142/92. A follow up April 2008 record noted a past medical history of hypertension. In April 2008, a VA clinician observed normal blood pressure. Further, hypertension was not diagnosed during an Agent Orange screening examination later in April 2008. Nevertheless, a diagnosis of hypertension was carried forward by VA clinicians through September 2012 but without a notation of the use of prescribed medication for control. The Veteran was diagnosed with diabetes mellitus by private and VA clinicians in 2008. In a September 2011 VA examination to evaluate the severity of diabetes, a VA physician checked boxes on a disability benefits questionnaire indicating that the Veteran's hypertension was not caused or aggravated by diabetes. The physician did not explain the conclusion or refer to any previous service or post-service treatment history. At the August 2012 Board hearing, the Veteran contended his hypertension was secondary to his service-connected diabetes mellitus, type II. He testified that his diabetes must have developed before 2008 and was likely concurrent with his hypertension in 2004. On remand, the Veteran was afforded a VA examination in January 2013, at which time the claims file was reviewed. It was noted that, for VA purposes, for the initial diagnosis of hypertension or isolated systolic hypertension, such must be confirmed by readings taken two or more times on at least three different days. Blood pressure results may be obtained from existing medical records or through scheduled visits for blood pressure measurements. The Veteran reported taking home remedies for hypertension in 1971 or 1972. He was not seeing a doctor. However, he indicated that he was told to stop eating red meat. He had never been on medication for hypertension and was not currently on medication. After reviewing the claims file and examining the Veteran, the examiner determined that the Veteran did not have hypertension. The examiner stated that the Veteran did not have hypertension nor had he ever met the criteria for a diagnosis of hypertension. As such, given the lack of diagnosis, hypertension did not manifest within one year of his service discharge and was not proximately due to or aggravated by his diabetes mellitus, type II, or psychiatric disorder. The examiner observed that review of VA treatment records revealed that the Veteran had never been treated for hypertension and his vitals had not met the criteria. Moreover, review of the claims file did not reveal any blood pressure readings diagnostic of hypertension. Vitals taken over the last two years reveal that the Veteran had not met the criteria for hypertension. Further, the Veteran had never been given medication for hypertension. It was also noted that on his Agent Orange examination in April 2008, the Veteran was not diagnosed with hypertension and was not on medication for hypertension. Therefore, based on the evidence of record, the Board finds that a preponderance of the competent medical evidence is against a finding that the Veteran currently has hypertension for VA purposes. There was no diagnosis of hypertension in service or within one year of service so the service incurrence of hypertension may not be presumed. Significantly, the January 2013 VA examination determined that the Veteran had never met the criteria for a diagnosis of hypertension and offered a detailed rationale for this opinion. Given that the claims file was reviewed by the examiner and the examination report sets forth detailed examination findings in a manner which allows for informed appellate review under applicable VA laws and regulations, the Board finds the examination to be sufficient and of high probative value. The Court has indicated that in the absence of proof of a present disability, there can be no valid claim for service connection as Congress has specifically limited entitlement to service connection to cases where such incidents have resulted in a disability. Brammer v. Derwinski, 3 Vet. App. 223 (1992). The Court has held that the requirement of a current disability is satisfied when the claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim, and that a claimant may be granted service connection even though the disability resolves prior to adjudication of the claim. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). The Court recently issued a decision in Romanowsky v. Shinseki, 2013 WL 3455655(July 10, 2013), that found that the Board erred when it did not consider whether the appellant's adjustment disorder, diagnosed prior to the claim period, was extant at the time he filed his claim but had resolved by the time of the later examination. Therefore, the Board will also look to the evidence prior to the claim period. See McClain, 21 Vet. App. at 321 (noting that the "current disability" required for service connection includes a disability at the time of filing or during the pendency of a claim); but see Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (stating that "simply because [the Veteran] had a disease or injury while on active service" was insufficient to obtain benefits "[i]n the absence of proof of a present disability"). The Board recognizes that private and VA treatment records have showed a diagnosis of hypertension. However, in the instant case, as observed by the January 2013 VA examiner, any diagnosis made was never based on the Veteran actually meeting the diagnostic criteria for hypertension. Significantly, the Veteran has never been treated for hypertension and has never taken medications for hypertension. It appears that all diagnoses of hypertension were based on the Veteran's reported medical history as opposed to diagnostic criteria. In this regard, there is nothing in the Veteran's medical history that indicates that he was diagnosed with hypertension. Therefore, his report of such is not credible. Kowalski v. Nicholson, 19 Vet. App. 171, 179 (2005) (in evaluating medical opinion evidence, the Board may reject a medical opinion that is based on facts provided by the Veteran that have been found to be inaccurate or because other facts present in the record contradict the facts provided by the Veteran that formed the basis for the opinion). Therefore, to whatever extent these records show a diagnosis of hypertension, such would be based on unsubstantiated medical history and would not be entitled to any probative weight. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993); Swann v. Brown, 5 Vet. App. 229, 233 (1993) (holding that as a medical opinion can be no better than the facts alleged by a Veteran, an opinion based on an inaccurate factual premise has no probative value). Moreover, in the instant case, based on the January 2013 VA examination findings, the Veteran has not suffered from a current disability at any point during the course of the appeal or, for that matter, prior to the appeal period. The examiner clearly determined that the Veteran had never had hypertension or been treated for hypertension. Given that the examination is based on a complete review of the claims file, a thorough examination of the Veteran, and offered a detailed rationale for its findings, the Board finds that the examination outweighs the private and VA treatment records. The Board observes that lay assertions may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C.A. § 1153(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). Citing Buchanan and Jandreau, the Federal Circuit recently reiterated that it had previously consideration and explicitly rejected the view that medical evidence is required when the determinative issue in a claim for benefits involves either medical etiology or a medical diagnosis. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Specifically in Jandreau, 492 F.3d 1372 (Fed. Cir. 2007), the Federal Circuit commented that competence to establish a diagnosis of a condition can exist when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Similarly, the Court has held that when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303 (2007). When applying the case law discussed above, here, the Veteran is competent to say describe symptoms and to report a continuity of symptoms since service. However, while he can describe symptoms, he is not competent to diagnose hypertension as certain diagnostic criteria must be met for such a diagnosis. Given that blood pressure readings and a medical examination is necessary for such a diagnosis, the Board finds that medical experience is required to diagnose hypertension and that the Veteran has not shown that he has such experience. Thus, his contentions that he currently has hypertension are outweighed by the medical evidence of record, specifically, the highly probative January 2013 VA examination. In conclusion, the preponderance of the evidence is against service connection for hypertension. As the preponderance of the evidence weighs against the claim, the benefit-of-the-doubt doctrine does not apply. See 38 U.S.C.A. § 5107(b). ORDER Service connection for hypertension is denied. REMAND Unfortunately, although the Board regrets the additional delay, a remand is necessary with respect to the remaining issue on appeal to ensure that there is a complete record upon which to decide the Veteran's claim so that he is afforded every possible consideration. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. Upon review of the claims file, the Board finds that all of the development directed by the Board in its prior remand was not accomplished. Where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance. Stegall, supra. Initially, the Board remanded this case and directed the AOJ to obtain VA medical records from the Shreveport VA Medical Center (VAMC) dated from 1970, from 1990 to March 2008, and from August 2012 to the present. While the AOJ obtained additional VA treatment records from August 2012 to December 2012, it failed to obtain any prior VA treatment records as directed by the Board. The Board observes that such records were requested by the AOJ in December 2012. However, the record is silent with respect to any response to this request. Moreover, the Board specifically directed the AOJ to issue a formal determination if such records were not available and notify the Veteran, which was not done. Thus, in order to comply with the Board's December 2012 remand, the AOJ must take additional action with regard to these VA treatment records. The AOJ was also directed to request from the Veteran's VA physician, J. H.L., Ph.D., at the Overton Brooks VA Medical Center, a statement identifying the Veteran's current acquired psychiatric disorders, to include PTSD, and an opinion as to whether his specific diagnosed psychiatric disorders were caused by actual or threat of hostile attack that the Veteran experienced in service in Korea or any other aspect of service. However, instead of requesting this statement directly, the AOJ in December 2012 simply instructed the Veteran to make the request. Nevertheless, this opinion would be considered in the custody of a Federal facility and, in turn, the requirements set forth under 38 C.F.R. § 3.159(c)(2) for obtaining such records must be followed. Thus, again, the case must be returned so the AOJ can request such statement from the Veteran's VA physician. Finally, the Board directed the AOJ that, if such statement was not obtained, to afford the Veteran a VA psychiatric examination. The Board specifically directed that the claims file be reviewed in conjunction with the examination. The Veteran was afforded a VA examination in January 2013. The examiner determined that the Veteran did not meet the criteria for a diagnosis of PTSD and any other diagnosed psychiatric disorder was not related to his service. However, the claims file was not available for review. With respect to a service connection claim, it is imperative that the claims file be reviewed by the examiner for historical reference. The examiner also based his opinion in part on having no confirmation of what happened in Korea. Although he did observe that the Veteran reported fearing for his life when tracer fire would occur from the North Koreans, and this was consistent with a fear of hostile miliary or terrorist activity, the examiner indicated that it was not clear to him if this claimed stressor was typical of the conditions, places and situation of the Veteran's deployment and deferred the matter to the AOJ for confirmation. He also found that the Veteran was not a credible historian. Nevertheless, as observed in the prior remand, service personnel records showed that the Veteran served as a U.S. Army infantryman including a tour of duty with the 1st Battalion, 32 Infantry Regiment, 2nd Infantry Division positioned at the Demilitarized Military Zone (DMZ) in Korea from April 1969 to February 1970. In written statements and in testimony before the Board in August 2012, the Veteran reported that he received a diagnosis and treatment for PTSD, anxiety, and depression arising from participation in small arms engagements with enemy forces at the DMZ and constant apprehension of hostile attack. Publications in the claims file confirm such incidents. Service connection for PTSD requires medical evidence establishing a diagnosis of the condition in accordance with 38 C.F.R. § 4.125(a) (i.e., the diagnosis must comply with the Fourth Edition of the Diagnostic and Statistical Manual of Mental Disorders, 1994 (DSM-IV)); in certain circumstances, credible supporting evidence that the claimed in-service stressor occurred; and a link, established by medical evidence, between current symptomatology and the claimed in-service stressor. See 38 C.F.R. §§ 3.304(f), 4.125; see also Cohen v. Brown, 10 Vet. App. 128, 140 (1997). If a stressor claimed by a Veteran is related to the Veteran's fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of PTSD, and that the Veteran's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the Veteran's service, the Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304 (f) (3); 75 Fed. Reg. 39,843 (Jul. 13, 2010). In the instant case, based on the publications received and the Veteran's service in Korea at the DMZ, it would appear that his claimed stressor is consistent with the places, types and circumstances of his service. Thus, the VA examiner's rationale appears to be based on the inaccurate assumption that the Veteran's claimed stressor was not consistent with his service in Korea. The Court has held that a medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Nieves- Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A]medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). Moreover, once VA undertakes the effort to provide an examination for a service connection claim, even if not statutorily obligated to do so, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided). Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Accordingly, given the deficiencies described above in the January 2013 VA examination report, the Board finds that another VA examination with a different examiner, if possible, should be afforded to the Veteran to determine the nature, extent and etiology of his any diagnosed psychiatric disorders, to include PTSD. It is imperative that the claims file be reviewed in conjunction with the examination. Accordingly, the case is REMANDED for the following action: 1. Request records of VA medical care provided at the Shreveport VA Medical Center in 1970, from 1990 to March 2008, and from August 2012 to the present. All reasonable attempts should be made to obtain any identified records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C.A. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 2. Request from the Veteran's VA physician, J. H.L., Ph.D., at the Overton Brooks VA Medical Center, a statement identifying the Veteran's current acquired psychiatric disorders, to include PTSD, and an opinion as to whether his specific diagnosed psychiatric disorders were caused by actual or threat of hostile attack that the Veteran experienced in service in Korea or any other aspect of service. He must provide reasons in support of his conclusions. 3. After obtaining all available treatment records, schedule the Veteran for a VA mental health examination to be conducted by a psychiatrist or psychologist, with an examiner other than the examiner who conducted the January 2013 VA examination, if possible. Request that the examiner review the claims file and note the review in the examination report. Any indicated evaluations, studies, and tests should be conducted. a. Identify all of the Veteran's acquired psychiatric disorders that meet the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV) criteria. b. Specifically indicate whether the Veteran meets the diagnostic criteria for PTSD and whether such diagnosis is the result of actual or threat of hostile attack that the Veteran experienced in service in Korea or any other aspect of service. The examiner is advised that the Veteran's stressors related to his fear of hostile military activity are considered consistent with the circumstances of his service in Korea. c. For each currently diagnosed acquired psychiatric disorder other than PTSD, it should be indicated whether it is at least as likely as not that any such disorder is related to the Veteran's military service, to include his experiences in Korea. The examiner must provide a detailed rationale for all opinions. 4. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the Veteran's claim should be readjudicated based on the entirety of the evidence. If the claim remains denied, the Veteran and his representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. Thereafter, the case should be returned to the Board for further appellate consideration, if otherwise in order. The Board intimates no opinion as to the outcome of this case. The Veteran need take no action until so informed. T he purpose of this REMAND is to ensure compliance with due process considerations. The Veteran has the right to submit additional evidence and argument on the matter 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 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). ______________________________________________ A. JAEGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs