Citation Nr: 18149904 Decision Date: 11/14/18 Archive Date: 11/14/18 DOCKET NO. 14-28 437A DATE: November 14, 2018 ORDER Entitlement to service connection for an acquired psychiatric disability, to include posttraumatic stress disorder (PTSD), is granted. REMANDED Entitlement to service connection for a kidney condition, including as secondary to diabetes mellitus type II (DM), is remanded. FINDING OF FACT It is at least as likely as not the Veteran has PTSD as a result of his active service. CONCLUSION OF LAW The criteria for entitlement to service connection for an acquired psychiatric disability, to include PTSD, have been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from September 1969 to September 1971. He had active service in Vietnam and his awards include the Vietnam Service Medal and the Vietnam Campaign Medal. This matter is before the Board of Veterans’ Appeals (Board) on appeal of April 2012 and August 2012 rating decisions of a Regional Office (RO) of the Department of Veterans Affairs (VA). Entitlement to service connection for an acquired psychiatric disability, to include PTSD Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection requires evidence showing: (1) the existence of a present disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection for PTSD generally requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. See Cohen v. Brown, 10 Vet. App. 128, 139-43 (1997); 38 C.F.R. § 3.304(f). If a claimed stressor is related to the fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a PTSD diagnosis and that the claimant's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the claimant's service, the claimant's lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304 (f)(3). For purposes of 38 C.F.R. § 3.304(f)(3), “fear of hostile military or terrorist activity” means the claimant experienced, witnessed, or was confronted with an event or circumstances that involved actual or threatened death or serious injury, or a threat to the physical integrity of the claimant or others, such as from an actual or potential improvised explosive device, vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the claimant's response to the event or circumstances involved a psychological or psycho-physiological state of fear, helplessness, or horror. Id. When there is an approximate balance of positive and negative evidence regarding any material issue, reasonable doubt will be resolved in favor of the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Here, the Veteran’s military personnel records and Form DD214 document service in Vietnam from October 1970 to September 1971. He performed the duties of a cook. The Veteran provided written statements of December 2011 and August 2014 recounting his experience of coming under attack by bombs and mortars, working in a hospital with injured service members, and providing food service in the field, where he feared for his life. His reported stressors are consistent with his assigned duties and service in Vietnam. The Board finds them credible. A February 2012 VA PTSD examination diagnosed the Veteran as suffering from depressive disorder NOS and not PTSD. The examiner determined that the Veteran did not meet the DSM-4 diagnostic criteria for PTSD, although his reported stressor, being exposed to the deaths of American soldiers, was sufficient to support a diagnosis of PTSD. The examiner noted the Veteran had recurrent and distressing recollections of the stressor, made efforts to avoid thoughts about the trauma, had markedly diminished interest or participation in significant activities, and an exaggerated startle response. However, the symptoms exhibited did not fully meet the diagnostic criteria for PTSD applicable at that time. A February 2018 VA PTSD examination diagnosed the Veteran as suffering from PTSD. The examiner determined that the Veteran’s report of being shot at, shooting back, and fearing for his life in Vietnam supported the PTSD diagnosis. The Veteran’s reported symptoms of recurrent intrusive memories and distressing dreams, avoidance of memories and external reminders, diminished interest or participation in significant activities, hypervigilance, and sleep disturbance. These symptoms lasted more than one month and cause clinically significant distress. They were not attributable to substance use or another medical condition. The examiner determined the Veteran fully met the now applicable DMS-5 PTSD diagnostic criteria. The examiner opined the Veteran’s PTSD is more likely than not related to his active service. The February 2012 and February 2018 VA examinations are both probative of the issue at hand. The February 2012 examiner confirmed an adequate stressor. Although insufficient to support a diagnosis, multiple symptoms associated with PTSD were present. As the examination, was conducted under older diagnostic criteria, it is not dispositive of the claim. The February 2018 opinion, based on the current diagnostic criteria, confirms a PTSD diagnosis and a medical link to a confirmed stressor. Thus, the Board finds the evidence supporting a diagnosis of PTSD, the occurrence of a stressor, and a nexus between the stressor and service is at least in a state of equipoise. Entitlement to service connection for PTSD is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND Entitlement to service connection for a kidney condition, including as secondary to diabetes mellitus type II (DM) VA has a duty to ensure any medical examination or opinion it provides is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (overruled on other grounds, Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013)). A medical opinion is adequate where it is based upon consideration of the full medical history and describes a disability in sufficient detail so that the Board's evaluation will be fully informed. Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). The Veteran claims he suffers from a kidney disability caused by or aggravated by service connected DM. The Veteran submitted an August 2012 note from his private physician, Dr. A. in support of his claim. The doctor opined the Veteran’s “renal function decline is most likely associated with DM.” The opinion does not provide a diagnosis of a kidney disability and it is not supported by any explanation or rationale. It is insufficient to determine the claim. See Stefl, supra. A May 2012 VA kidney examination was provided to evaluate the Veteran’s claim. The examiner noted that the Veteran had been diagnosed a kidney disability of “slight decrease in EGFR2, ‘stage 2 kidney disease.’” The examiner then opined the kidney condition was less likely than not proximately due to or the result of the Veteran’s DM because there was “minimal early evidence of renal dysfunction. Microalbinuria examinations have been negative. Multiple urine protein examinations negative. Multiple EGFRs > 60.” The rationale provided, that there is minimal evidence of a kidney condition, is contradictory to the diagnosis of “stage 2 kidney disease” listed in the diagnostic section of the examination report. In addition, the opinion does not provide a clear explanation as to why the test results identified support the conclusion that any kidney disfunction is not related to DM. The medical opinion is insufficient to evaluate the claim and a new examination must be provide. Id. The matter is REMANDED for the following action: 1. Obtain and associate with the claims file any additional medical evidence that may have come into existence but has not been associated with the record. 2. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any kidney disability. The claims file must be reviewed by the examiner. Following a review of the claims file and any clinical examination results, the examiner should opine whether any kidney disorder diagnosed is at least as likely as not (i.e. 50 percent probability or more) (1) proximately due to service-connected DM, or (2) aggravated beyond its natural progression by service-connected DM. The examiner is advised aggravation means an increase in the severity of the underlying disability beyond its natural progression. If aggravation is found, the examiner should attempt to quantify the degree of additional disability resulting from the aggravation by establishing the baseline level of severity of the kidney disorder prior to aggravation by the DM. All opinions are to be accompanied by a rationale consistent with the evidence of record. A discussion of the pertinent evidence, relevant medical treatises, and generally accepted medical principles is requested. If the examiner cannot provide an opinion without resorting to speculation, he or she shall provide complete explanations stating why this is so. In so doing, the examiner shall explain whether any inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. 3. After completing the above, and any other development deemed necessary, readjudicate the appeal. If the benefit sought remains denied, provide an additional supplemental statement of the case to the Veteran and his representative, and return the appeal to the Board. J. GALLAGHER Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Jeanne Celtnieks, Associate Counsel