Citation Nr: 18141493 Decision Date: 10/10/18 Archive Date: 10/10/18 DOCKET NO. 14-36 730 DATE: October 10, 2018 REMANDED Entitlement to an increased rating for residuals of right fibula fracture with continuing ankle disability, currently evaluated as 30 percent disabling, is remanded. Entitlement to service connection for a heart disorder is remanded. REASONS FOR REMAND As to the claim for right fibular fracture with ankle disability, although the Veteran was most recently evaluated in March 2017, at a March 2018 Board hearing, he testified that his right leg had subjectively worsened since his last examination. In light of this suggestion of a possible worsening of his right leg disability, the Board finds a that new VA examination is warranted. See Green v. Derwinski, 1 Vet. App. 121 (1991) (VA has a duty to conduct a thorough and contemporaneous examination of the Veteran in an increased rating claim); Schafrath v. Derwinski, 1 Vet. App. 589 (1991); see also Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). As to the claim for a heart disorder, in August 2013, a VA examiner essentially opined that the Veteran did not have a current heart disorder and therefore no heart disorder was related to service. In a September 2018 report of general information, the Veteran stated that he suffered a heart attack in May or June of 2018 and that there were treatment records from the Lexington Medical Center in South Carolina that were relevant to the appeal. These records are not currently associated with the claims file. Hence, after obtaining these records, an addendum opinion should be obtained. In addition, any outstanding VA treatment records should be associated with the claims file. The matters are REMANDED for the following action: 1. Associate with the claims file the all outstanding VA treatment records, to include any records from the VA Medical Center in Columbia, South Carolina from July 2017 to the present and the VA Medical Center in Charleston, South Carolina from February 2017 to the present. 2. Send to the Veteran a letter requesting that he provide sufficient information and a signed and dated authorization, via a VA Form 21-4142 (Authorization and Consent to Release Information) to enable VA to obtain any relevant private medical records, including any treatment from Lexington Medical Center in South Carolina. 3. Thereafter, forward the entire claims file in electronic records and a copy of this remand to an appropriate VA examiner for an addendum opinion addressing the etiology of any current heart disorder. If examination is indicated, it should be scheduled in accordance with applicable procedures. The examiner should first identify all current heart disorders. Then, for each diagnosed disability, the examiner should indicate whether it is as least as likely as not (50 percent probability or more) that it is related to the Veteran’s active duty service. The rationale for all opinions expressed must be provided. 4. The Veteran should be afforded a VA examination to evaluate the current severity of the right fibula fracture with continuing ankle disability. The electronic claims folders should be made available to the examiner for review in conjunction with the examination and the examiner should acknowledge such review in the examination report. Any indicated studies should be performed. The examination should be conducted in accordance with the current disability benefits questionnaires or examination worksheets applicable to the lower leg to include the knee and ankle. Range of motion in active motion, passive motion, weight-bearing, and nonweight-bearing, for the joint in question, and any opposing undamaged joint, must be conducted. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. The rationale for all opinions expressed must be provided. 5. After completion of the above, readjudicate the claims. If any benefit requested on appeal is not granted to the Veteran’s satisfaction, the appellant and his representative should be furnished a supplemental statement of the case, and provided an opportunity to respond. The case should then be returned to the Board for further appellate consideration, if in order. GAYLE STROMMEN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Matthew Schlickenmaier, Counsel