Citation Nr: 18146274 Decision Date: 10/31/18 Archive Date: 10/30/18 DOCKET NO. 14-39 944 DATE: October 31, 2018 REMANDED Entitlement to service connection for a right knee disability is remanded. Entitlement to service connection for headaches is remanded. Entitlement to service connection for an acquired psychiatric disorder is remanded. Entitlement to service connection for a bilateral hearing loss disability is remanded. Entitlement to service connection for tinnitus is remanded. REASONS FOR REMAND The Veteran had active service from May 1988 to October 1992. His decorations include the Kuwait Liberation Medal. These matters are before the Board of Veterans’ Appeals (Board) on appeal from rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). 1. Entitlement to service connection for a right knee disability is remanded. 2. Entitlement to service connection for headaches 3. Entitlement to service connection for an acquired psychiatric disorder 4. Entitlement to service connection for a bilateral hearing loss disability 5. Entitlement to service connection for tinnitus The evidence indicates there may be outstanding relevant VA treatment records. A September 18, 2013 VA treatment record indicates that the Veteran was to return for follow up appointment in September 2014. VA treatment records subsequent to September 18, 2013 have not been associated with the claims file. Additionally, VA treatment records from March 15, 2011 and February 23, 2011 note that outside physical therapy records had been scanned into VistA Imaging. It does not appear that the referenced records have been associated with the claims file. A remand to obtain the records is required. The Veteran's service treatment records do not contain any psychiatric clinical or inpatient substance abuse treatment program records. The Veteran reports that he received six weeks of inpatient substance abuse treatment and was confined in a psychiatric facility for two days during service. As such records may be kept separately from other service treatment records, a request for any psychiatric treatment or inpatient substance abuse treatment program records should be made. To date, it does not appear that the Veteran’s complete service personnel records have been obtained. Specifically, while the record indicates that the Veteran had disciplinary infractions during service it is not documented in the current service personnel records. As such records may contain information relevant to the Veteran’s claims, a remand is required to obtain them. The Veteran was provided a right knee examination in August 2013. Nevertheless, as the examiner’s negative opinion only address the Veteran’s “soft tissue injury of the right knee in 1992” and did not address his other documented reports of right knee pain, including those in March 1989, December 1989, July 1990, September 1991, and October 1991 an addendum opinion is required. Regarding the Veteran’s claim for headaches, his service treatment records document treatment for headaches in May 1989 and September 1989. VA treatment records also note intermittent treatment for headaches. Accordingly, the Board cannot make a fully-informed decision on the claim because no VA examiner has opined whether the Veteran’s headaches are related to his military service. Concerning the Veteran’s claim for an acquired psychiatric disorder, the record contains various diagnoses including depression, anxiety, dysthymia, adjustment disorder, “probable PTSD,” and attention deficit hyperactivity disorder. The Board notes the August 2013 VA opinion indicated that the Veteran did not meet the criteria for PTSD and that his other psychiatric disorders pre-existed service. However, the opinion is conclusory, and a remand for a VA examination and opinion is warranted. Finally, while the Veteran reported for a VA audiological examination the examination was postponed because the Veteran had a wax impaction that needed to be removed prior to audiological evaluation. To date, the Veteran has not been rescheduled for a VA audiological examination. Accordingly, on remand the Veteran should be provided a VA audiological examination to address his hearing loss and tinnitus claims. The matters are REMANDED for the following actions: 1. Ask the Veteran to provide the names and addresses of all medical care providers who have recently treated him for his claimed disabilities. After securing any necessary releases, request any relevant records identified. In addition, obtain updated VA treatment records and the VistA Imaging record referenced in to the March 15, 2011 and February 23, 2011 VA treatment records. If any requested records are unavailable, the Veteran should be notified of such. 2. Request all in-service psychiatric, counseling treatment records, and substance abuse treatment program records, through official sources. If additional information is needed from the Veteran to request such records, the Veteran should be asked to provide it. All efforts to obtain such records should be documented in the claims file. If the requested records do not exist or cannot be obtained, the Veteran should be notified of such. 3. Obtain the Veteran’s complete service personnel records. If the requested records do not exist or cannot be obtained, the Veteran should be notified of such. 4. After the above is completed to the extent possible, forward the claims file to a VA clinician to obtain an addendum opinion regarding the Veteran's right knee. If an examination is deemed necessary to respond to the questions presented, one should be scheduled. Following review of the claims file, the clinician should opine whether it is at least as likely as not (50 percent probability or greater) that any right knee disability had its onset during service or is otherwise related to service, to include the Veteran’s right knee pain in March 1989, December 1989, July 1990, September 1991, and October 1991. A complete rationale should be provided for all opinions and conclusions expressed. 5. The Veteran should be afforded a VA neurological examination to determine the nature of his headaches and to obtain an opinion as to whether such is possibly related to service. The claims file should be reviewed by the examiner in conjunction with the examination. All necessary tests should be conducted and the results reported. Following review of the claims file and examination of the Veteran, the examiner should: (a.) Identify any disability manifested by headaches and state whether it is at least as likely as not (50 percent probability or greater) that it arose during service or is otherwise related to service, to include his service in the Persian Gulf and in-service treatment for headaches. The examiner should also address the Veteran’s assertion that his current headaches are related to his in-service medications, including Antabuse, Motrin, and Flexeril. (b.) If there is no diagnosis to account for the Veteran’s headache symptoms, the examiner should indicate whether there are objective indications of disability and whether such indications represent an undiagnosed illness consistent with service in the Persian Gulf. A rationale for all opinions expressed should be provided. 6. Schedule the Veteran for a VA PTSD examination. The claims file should be reviewed by the examiner in conjunction with the examination. All indicated tests should be conducted and the results reported. Following review of the claims file and examination of the Veteran, the examiner should identify all psychiatric disorders present and then respond to the questions presented: (a.) If the Veteran is diagnosed with PTSD, the examiner should indicate the stressor(s) upon which the diagnosis is based. (b.) For each diagnosed psychiatric condition other than PTSD and personality disorders, to include depression, anxiety, dysthymia, adjustment disorder, and attention deficit hyperactivity disorder noted in treatment records, state whether it is at least as likely as not (50 percent probability or greater) that the conditions arose during active service or are otherwise related to the Veteran’s active service. In so opining, the examiner should address the Veteran’s in-service treatment for “an acute anxiety reaction” in October 1989. (c.) If the examiner finds that any psychiatric condition undebatably existed prior to active service, the examiner should provide a complete rationale in support of that finding and opine whether the pre-existing psychiatric condition underwent a permanent worsening during active service? Please explain why or why not. (d.) If the preexisting condition was permanently worsened during service, was that worsening undebatably due to the natural progress of the disability? Please explain why or why not. A complete rationale for all opinions expressed should be provided. 7. The Veteran should be afforded a VA audiological examination to determine the nature of the Veteran’s claimed hearing loss and tinnitus and to obtain an opinion as to whether such is possibly related to service. The claims file should be reviewed by the examiner in conjunction with the examination. All necessary tests should be conducted and the results reported. Following review of the claims file and examination of the Veteran, the examiner should: (a.) State whether it is at least as likely as not (a probability of 50 percent or greater) that any current hearing loss had its onset during active service or is related to any in-service disease, event, or injury. (b.) State whether it is at least as likely as not (a probability of 50 percent or greater) that any current tinnitus had its onset during active service or is related to any in-service disease, event, or injury. A complete rationale for all opinions expressed should be provided. K. A. BANFIELD Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J. Anderson