Citation Nr: 1746927 Decision Date: 10/20/17 Archive Date: 10/31/17 DOCKET NO. 13-30 494 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to an initial rating greater than 50 percent for posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for a left leg/knee condition. 3. Entitlement to service connection for a left foot condition. REPRESENTATION Veteran represented by: The American Legion WITNESSES AT HEARING ON APPEAL The Veteran and his daughter ATTORNEY FOR THE BOARD L. Sinckler, Associate Counsel INTRODUCTION The Veteran served on active duty from March 1966 to March 1969. He was awarded a Combat Infantryman Badge and a Purple Heart. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2011 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. The Veteran testified at a video-conference hearing before the undersigned Veterans Law Judge (VLJ) in December 2016. A transcript is of record. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if further action is required. REMAND Unfortunately, a remand is required in this case. While the Board sincerely regrets the delay, the Veteran's claims are remanded for further development in accordance with VA's duty to assist. Such development is necessary to aid the Board in making an informed decision, and will help ensure that the claims are afforded every consideration. The Veteran was last afforded a VA examination addressing the severity of his service-connected PTSD in May 2011. In his December 2016 Board Hearing, the Veteran asserted that his PTSD disability had worsened since his last exam. See December 2016 Board Hearing. Accordingly, given the suggestion that the Veteran's disability picture has changed, a new VA examination is warranted to assess the current level of severity of his service-connected PTSD. See 38 C.F.R. § 3.327(a) (2016) (providing that reexaminations will be requested whenever VA needs to determine the current severity of a disability). See also Palczewski v. Nicholson, 21 Vet. App. 174, 181-82 (2007), citing Caluza v. Brown, 7 Vet. App. 498, 505-06 (1998) ("Where the record does not adequately reveal the current state of the claimant's disability . . . the fulfillment of the statutory duty to assist requires a thorough and contemporaneous medical examination."); Olsen, 3 Vet. App. at 482; Proscelle v. Derwinski, 2 Vet. App. at 632; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Additionally, there appear to be outstanding treatment reports. During his 2016 Board hearing, the Veteran mentioned receiving treatment for his PTSD from a doctor in Raleigh, North Carolina, on a contract basis through VA. Furthermore, as this case is being remanded, the RO should make another attempt to obtain the Veteran's private treatment records for his left foot and leg/knee from Urgent Care Carolina Doctors Medcare. With respect to his left foot and knee/leg, the Veteran stated that he sustained an injury from an incoming round. It appears that his service treatment records are incomplete. As noted above, he was awarded a Purple Heart. See 38 U.S.C.A. § 1154(b). However, there is no indication of treatment for any injuries in his service treatment records. Therefore, an additional request for these records must be made on remand, as well as for the Veteran's service personnel records. Finally, the Veteran has described an in-service injury to his left foot and leg/knee from an incoming round. He was also awarded a Parachute Badge. On separation examination in January 1969, he complained of exertional and nocturnal leg cramps, and he testified in 2016 that he has recently been treated for left foot and leg/knee disorders. Accordingly, he should be scheduled for an appropriate VA examination on remand to determine whether any current left foot and leg/knee disorder is related to any incident of service. Accordingly, the case is REMANDED for the following action: 1. Contact the Veteran and ask him to identify all medical care providers that have treated him for his left foot and/or left leg/knee disorder, including, but not limited to Urgent Care Carolina Doctors Medcare. Then, make arrangements to obtain all records that he adequately identifies. 2. Make arrangements to obtain the Veteran's complete VA treatment records. Special attention is directed to psychiatric records from a doctor in Raleigh, North Carolina, who treats the Veteran via a VA contract. 3. Make arrangements to obtain the Veteran's complete service treatment records, to include all clinical records. 4. Make arrangements to obtain the Veteran's complete service personnel records, to include all records concerning his award of the Purple Heart. 5. Thereafter, schedule the Veteran for an appropriate VA examination of his left foot and left leg/knee. The entire claims file and a copy of this REMAND must be made available to the examiner in conjunction with the examination. The examiner must note in the examination report that the evidence in the claims file has been reviewed. The examination should include any diagnostic testing or evaluation deemed necessary by the examiner. The examiner should obtain a complete history from the Veteran concerning any injuries to his left lower extremity during service, to include as a result of being hit by incoming rounds and/or performing parachute jumps. The examiner should also obtain a complete history from the Veteran concerning his post-service symptoms and treatment. The examiner should identify all current left foot and left leg/knee disorders found to be present. For each diagnosed left foot and left leg/knee disorder, the examiner must render an opinion as to whether it is at least as likely as not (50 percent or greater probability) that it had its clinical onset during active service or is related to any incident of service, to include as a result of being hit by incoming rounds (bullets and scrap metal) and/or performing parachute jumps. In providing this opinion, the examiner should acknowledge the Veteran's complaints of exertional and nocturnal leg cramps on separation examination in January 1969. The examiner must provide a comprehensive report including complete rationales for all opinions and conclusions reached, citing the objective medical findings leading to the conclusions. 6. Schedule the Veteran for an appropriate VA examination to determine the severity of his service-connected PTSD. The Veteran's claims file, including a copy of this remand, must be made available to and reviewed by the hearing examiner. The examination report must reflect that such a review was undertaken. The examination should include any necessary diagnostic testing or evaluation. The examiner must identify the symptoms and functional impairment associated with the Veteran's PTSD, and discuss the degree of occupational and social impairment caused by his symptoms. Preferably, the appropriate Disability Benefits Questionnaire (DBQ) should be used for this purpose. The examiner must provide a comprehensive report including complete rationales for all opinions and conclusions reached, citing the objective medical findings leading to the conclusions. 7. Finally, after the above development is completed, and any other development that may be warranted based on any additional information or evidence received, readjudicate the claims on appeal. If the benefits sought are not granted, the Veteran and his representative should be furnished a supplemental statement of the case (SSOC) and 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 2014). _________________________________________________ P.M. DILORENZO Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2014), 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) (2016).