Citation Nr: 18143702 Decision Date: 10/22/18 Archive Date: 10/19/18 DOCKET NO. 08-26 249 DATE: October 22, 2018 REMANDED Entitlement to service connection for sinusitis is remanded. Entitlement to service connection for an acquired psychiatric disorder, to include PTSD is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1980 to March 1990. In September 2016, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. A transcript is of record. 1. Entitlement to service connection for sinusitis is remanded. The Veteran contends that she began to experience symptoms of a sinus disability during service and that she has continued to experience such symptoms since service. Service treatment records indicate that the Veteran sought treatment for several general upper respiratory infections including sinusitis and sinus pressure. The Veteran was afforded a VA examination in July 2017. The Board finds the VA examination is inadequate. First, under Section 1 (Diagnosis), the examiner indicated that the Veteran does not have or has ever been diagnosed with a sinus, nose, throat, larynx, or pharynx condition. Under Section 3 (Nose, throat, larynx, or pharynx condition), the examiner indicated that the Veteran has sinusitis. Second, the examiner failed to provide an adequate opinion. The examiner noted that the Veteran has had several acute sinusitis which she has been treated for since 1982. However, the examiner noted that the Veteran does not have chronic sinusitis and therefore, it is less likely as not that the Veteran has sinusitis related to service. The examiner offered no opinion as to etiology of the Veteran’s sinusitis. Therefore, another examination is necessary to address the etiology of the Veteran’s sinusitis, to include whether such is related to the Veteran’s military service. 2. Entitlement to service connection for an acquired psychiatric disorder, to include PTSD is remanded. The Veteran was afforded a VA examination in September 2017. The examiner indicated that the Veteran does not have a diagnosis of PTSD that conforms to DSM-5 criteria. The examiner also reported that the Veteran does not have any mental disorder diagnosis. The examiner expressed that the Veteran reported several stressors, and only one of which met criterion A for PTSD. The examiner expressed that while the Veteran’s stressful events may have been distressful, they fail to meet clinically significant levels of anxiety and depression. However, of record are VA treatment notes reflecting a positive screen for depression and that the Veteran was taking Venlafaxine for her depression. In addition, the Veteran submitted private medical records indicating that the Veteran presents symptoms of depression, anxiety, and avoidance related to military sexual trauma. Therefore, the September 2017 VA examination is inadequate and the Veteran must be afforded a new VA examination. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The matters are REMANDED for the following action: 1. Obtain updated VA treatment records. 2. After directive # 1 is complete, schedule the Veteran for a VA psychiatric examination from a different VA examiner than who performed the September 2017 examination (if possible). The entire claims folder and a copy of this REMAND must be made available to the examiner prior to the examination, and he or she should indicate on the examination report that such a review was completed. Based on a review of the record and the findings from clinical evaluation, the examiner should: Identify the nature of the Veteran’s current psychiatric diagnosis. If the Veteran does not meet the diagnostic criteria for PTSD, please expressly state so and why such diagnosis is not warranted. If a diagnosis of PTSD is appropriate, the examiner is asked to provide an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran has PTSD that is based on an in-service personal assault stressor. If the Veteran has a current diagnosed psychiatric disorder (other than PTSD), then the examiner should provide an opinion on whether it is at least as likely as not (a 50 percent probability or greater) that her diagnosed disorder is etiologically related to her period of service, to include her reported personal assault. The examiner is advised that for purposes of establishing service connection, a “current disability” includes a disability which existed at the time a claim for VA disability compensation is filed or during the pendency of the claim, even if that disability subsequently resolves. The examiner should provide a complete rationale for any opinion provided, and must address all relevant evidence. 3. After directive # 1 is complete, schedule the Veteran for a VA examination by a different VA examiner then who performed the July 2017 examination to determine the nature and etiology of any current disability of the nose and throat, to include sinusitis. The claims file, including this remand, must be reviewed by the examiner and such review should be noted in the examination report. After reviewing the claims folder and examining the Veteran the examiner must: Identify/diagnose all current sinus disorders and provide an opinion as to whether it is at least as likely as not (50 percent probability or more) that the Veteran’s sinus disorder was incurred during service. In rendering the opinion, the examiner is advised that service treatment records indicate that the Veteran was treated for several general upper respiratory infections including sinusitis and sinus pressure. The examiner is advised that for purposes of establishing service connection, a “current disability” includes a disability which existed at the time a claim for VA disability compensation is filed or during the pendency of the claim, even if that disability subsequently resolves. The examiner should provide a complete rationale for any opinion provided, and must address all relevant evidence. Nathaniel J. Doan Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M.D., Associate Counsel