Citation Nr: 18146166
Decision Date: 10/31/18	Archive Date: 10/30/18

DOCKET NO. 16-35 427A
DATE:	October 31, 2018
REMANDED
Entitlement to a rating in excess of 50 percent for posttraumatic stress disorder (PTSD) is remanded.
REASONS FOR REMAND
The Veteran served on active duty from July 1970 to March 1972, and January 1974 to December 1975.
This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a January 2015 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina.  
1. Entitlement to a rating in excess of 50 percent for posttraumatic stress disorder (PTSD) is remanded.
The Veteran was afforded a VA examination in August 2014.  Remand is necessary to obtain an updated examination to ascertain the current severity of the Veteran’s PTSD. 
The matter is REMANDED for the following action:
1. Obtain any outstanding VA and private medical records regarding the Veteran’s mental health treatment and associate them with the claims file. 
2. Schedule the Veteran for a VA examination to obtain an opinion as to the current severity of his PTSD.  All indicated tests and studies should be accomplished and the findings reported in detail. 
All relevant medical records must be made available to the examiner for review of pertinent documents.  The examination report should specifically state that such a review was conducted.  The examiner must provide a comprehensive explanation for all opinions provided.
In addition to any records that are generated as a result of this remand, the VA examiner’s attention is drawn to the following:
(a.) August 2012 VA Examination Report
(b.) July 2014 Lay Statement – Veteran reported symptoms including severe depression, crying spells, and nightmares
(c.) August 2014 VA Examination Report
(d.) July 2015 VA Medical Records (VAMRs) – Brain MRI report indicating the Veteran has small vessel ischemic disease
(e.) October 2015 VAMRs – Veteran admitted himself into the hospital due to suicidal ideation; reported auditory and visual hallucinations; given a suicidal safety plan and noted to need treatment for cocaine dependence 
(f.) December 2015 Lay Statement – Veteran reported symptoms including frequent anxiety attacks, suicidal ideation, inability to complete activities of daily living
(g.) April 2017 Lay Statement – Veteran reported symptoms including suicidal ideation, fear of leaving his home, anxiety attacks, irritability
3. Readjudicate the issue on appeal.  If any benefit sought on appeal remains denied, the Veteran should be provided a supplemental statement of the case (SSOC). An appropriate period should be allowed for response before the case is returned to the Board.
 
Vito A. Clementi
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	N. Miller, Associate Counsel