Citation Nr: 18144344 Decision Date: 10/24/18 Archive Date: 10/24/18 DOCKET NO. 16-31 598 DATE: October 24, 2018 REMANDED Entitlement to service connection for a duodenal ulcer, claimed as being secondary to posttraumatic stress disorder (PTSD), is remanded. Entitlement to service connection for gastroesophageal reflux disease (GERD), claimed as being secondary to PTSD, is remanded. Entitlement to a compensable disability rating for residuals, left hand disability, is remanded. Entitlement to a disability rating higher than 30 percent for PTSD is remanded. Entitlement to a total disability rating based on individual unemployability due to service connected disabilities (TDIU) is remanded. REASONS FOR REMAND 1. Entitlement to service connection for a duodenal ulcer and for GERD, both claimed as being secondary to PTSD, is remanded. The Veteran asserts in his February 2012 claim that his duodenal ulcer and GERD are caused and/or aggravated by anxiety and stress symptoms that are associated with his service-connected PTSD. The Veteran was afforded a VA examination of his claimed ulcer and GERD in March 2012. The examiner did not, however, offer an opinion as to whether the Veteran's duodenal ulcer and GERD were aggravated beyond their natural progression by the Veteran's PTSD. In the absence of such an opinion, the March 2012 examination is incomplete. The Veteran should be afforded a new examination of his duodenal ulcer and GERD. 38 C.F.R. § 3.159 (c)(4) (2017). 2. Entitlement to a compensable disability rating for residuals, left hand disability, is remanded. Service connection was awarded to the Veteran, effective from August 26, 1968, for left hand soft tissue injuries that resulted from an incident in which a stake was stuck in the palmar portion of the thenar web of his hand. In his February 2012 claim, he asserts that he has arthritis in his hand, and as such, a compensable disability rating should be awarded based on pain symptoms. Indeed, a private MRI and x-ray study of the Veteran's left hand revealed arthritis in the left wrist. It is unclear from those records, however, as to whether the arthritis changes were attributable to the Veteran's service-connected soft tissue injuries. Although the Veteran was afforded a VA examination of his left hand in June 2013, the examination did not include an examination of the Veteran's wrist and the examiner did not offer an opinion as to whether the left wrist arthritis is a manifestation of the service-connected soft tissue injuries. In the absence of such an opinion, the June 2013 examination is incomplete. The Veteran should be afforded a new hand examination to determine the manifestations, symptoms, and impairment associated with the Veteran's left hand disability. 38 C.F.R. § 3.159 (c)(4) (2017). 3. Entitlement to a disability rating higher than 30 percent for PTSD is remanded. The Veteran was most recently afforded a VA PTSD examination in June 2013. The corresponding report does not identify any reported or observed symptoms or social or occupational impairment. No mental status findings are reported. Indeed, it is unclear from the report as to whether the Veteran was even interviewed, and if so, what findings were noted by the examiner. The examiner commented only that the Global Assessment Functioning (GAF) score from the examination was virtually identical with that noted in a previous 2012 examination. In the absence of any express findings, the June 2013 examination is inadequate. In conjunction with the same, the Veteran reported during subsequent VA mental health treatment in 2016 and 2017 that his PTSD symptoms were worsening. During the May 2017 visit, he reported depression, feelings of worthlessness, and feeling as though life is not worth living. As the previous June 2013 examination was inadequate and the evidence indicates that there has been some worsening in the Veteran's PTSD symptoms, the Veteran should be afforded a new PTSD examination to determine the manifestations, symptoms, and impairment associated with the Veteran's PTSD. 38 C.F.R. § 3.159 (c)(4) (2017). 4. Entitlement to TDIU is remanded. The ultimate disposition of the issues on appeal will affect the analysis of the issue of the Veteran's entitlement to TDIU. As such, the issue of the Veteran's entitlement to TDIU is inextricably intertwined with the other issues remaining on appeal. As such, the issue of the Veteran's entitlement to TDIU must be deferred pending resolution of the intertwined issues. Harris v. Derwinski, 1 Vet. App. 180 (1991). The matters are REMANDED for the following action: 1. The Veteran should be asked whether he has additional evidence pertaining to his GERD, duodenal ulcers, left hand, PTSD, and/or other service connected disabilities. Records for relevant VA treatment received by the Veteran since December 2017 should be associated with the record. If such records are not available, such unavailability should be documented in the record. The Veteran and his representative should be notified of unsuccessful efforts to allow them the opportunity to obtain and submit those records for VA review. 2. Thereafter, schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of the Veteran's GERD and duodenal ulcer. The claims file should be reviewed in conjunction with the examination. All disorders exhibited by the Veteran during the appeal period should be identified. The examiner must opine as to whether it is at least as likely as not that any diagnosed disorder was: (1) incurred during the Veteran's active duty service; (2) proximately due to injuries or events incurred by the Veteran during his active duty service; or (3) was caused by OR was aggravated by the Veteran's service connected disabilities, to include symptoms associated with PTSD. 3. Thereafter, schedule the Veteran for a left hand and wrist examination to determine the severity of symptoms and functional impairment associated with the Veteran's service-connected left hand disability. The examiner should conduct all necessary tests and studies. The claims file should be reviewed in conjunction with the examination. The examiner should specifically note whether left wrist arthritis is a manifestation of the service-connected soft tissue injuries. 4. Thereafter, schedule the Veteran for a mental health examination to determine the severity of symptoms and functional impairment associated with the Veteran's service-connected PTSD. The examiner should conduct all necessary tests and studies. The claims file should be reviewed in conjunction with the examination. 5. After completion of the above development, the issues on appeal should be readjudicated. If the determination remains adverse to the Veteran, he and his representative should be furnished with a SSOC and be given an opportunity to respond. DONNIE R. HACHEY Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD D.S. Lee, Counsel