Citation Nr: 18149517
Decision Date: 11/09/18	Archive Date: 11/09/18

DOCKET NO. 15-38 998
DATE:	November 9, 2018
REMANDED
Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD) is remanded.
REASONS FOR REMAND
The Veteran served on active duty in the United States Army from June 1967 to May 1970. 
This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a September 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Buffalo, New York. 
Entitlement to an initial rating in excess of 30 percent for PTSD is remanded.
The Veteran seeks an initial rating in excess of 30 percent for his service-connected PTSD.  The Veteran contends that his symptoms are more severe than contemplated by his currently assigned disability rating.  
In May 2016, the Veteran’s spouse submitted a lay statement noting that the Veteran had nightmares, panic attacks at least twice a week, and was depressed.
Additionally, in a clinical pharmacy note from May 2016, the Veteran reported that he stopped taking his PTSD medication and experiences nightmares 1-3 times per week.  The Veteran also stated that he has irritability, starts arguments with his spouse, has difficulty sleeping, and is often fatigued.  The Veteran reported sweatiness, higher anxiety, and occasional flashbacks when triggered.  The Veteran stated that he no longer has the motivation or interest in activities, has poor concentration, and a reduced appetite.  The Veteran also stated that he no longer sees friends or goes to the gym.  The Psychiatric Pharmacy Resident that met with the Veteran stated within the medical record that the Veteran’s PTSD symptoms have markedly worsened since his last visit.
The Board notes that the Veteran last underwent a VA examination for PTSD in December 2015.  As the evidence of record indicates that the Veteran’s symptoms have increased in severity since he was last evaluated on examination, the Board finds that a remand is warranted to afford the Veteran a new VA examination to assess the current severity of his PTSD.  See Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); see also Green v. Derwinski, 1 Vet. App. 121, 124 (1991) (VA has a duty to provide the Veteran with a thorough and contemporaneous medical examination); Caffrey v. Brown, 6 Vet. App. 377, 381 (1994) (an examination too remote for rating purposes cannot be considered “contemporaneous”).  
The Board also notes that the last VA medical records found in the claims file are from December 2017, indicating that there may be more recent treatment records that have not yet been associated with the claims file.  On remand, the RO should obtain any outstanding VA medical records.    
The matter is REMANDED for the following action:
1. Obtain and associate with the claims file all outstanding VA medical records.  
2. Schedule the Veteran for a VA examination with a medical professional of appropriate expertise to assess the current nature and severity of his service-connected PTSD.  The VA examiner must review the claims file and should note that review in the report.  A complete history of symptoms should be elicited from the Veteran.    
3. After examining the Veteran and conducting any studies and/or tests deemed necessary, the VA examiner should fully describe all symptomatology and functional deficits associated with the Veteran’s service-connected PTSD and should opine as to their severity.  The Veteran’s lay statements regarding his symptomology must be recorded and taken into consideration.  The VA examiner should also comment on the Veteran’s current level of social and occupational impairment due to his service-connected PTSD.
4. After completing the above, re-adjudicate the claim.  If the benefit sought on appeal remains denied, issue a supplemental statement of the case.


 
LESLEY A. REIN
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	C. Mahaffey, Associate Counsel