Citation Nr: 18151111 Decision Date: 11/16/18 Archive Date: 11/16/18 DOCKET NO. 15-05 662 DATE: November 16, 2018 REMANDED Entitlement to service connection for a left shoulder disorder is remanded. Entitlement to service connection for a right shoulder disorder is remanded. Entitlement to service connection for a cervical spine disorder is remanded. Entitlement to service connection for a low back disorder is remanded. Entitlement to service connection for a left knee disorder, to include as secondary to a right ankle disorder, is remanded. Entitlement to service connection for a right knee disorder, to include as secondary to a right ankle disorder, is remanded. Entitlement to service connection for a right ankle disorder is remanded. Entitlement to service connection for bilateral hearing loss is remanded. Entitlement to service connection for tinnitus is remanded. Entitlement to service connection for gastroesophageal reflux disorder (GERD), to include as due to an acquired psychiatric disorder and/or as a result of other service-connected disorders, is remanded. Entitlement to service connection for a traumatic brain injury (TBI) is remanded. Entitlement to service connection for a headache disorder is remanded. Entitlement to service connection for a left hand tremor, to include as secondary to TBI, is remanded. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), anxiety, and/or depression, is remanded. Entitlement to service connection for a dental disorder is remanded. REASONS FOR REMAND The Veteran had active duty service from September 1993 to August 1996. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a May 2011 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a hearing before the undersigned Veterans Law Judge at the RO in April 2017. A transcript of that hearing has been associated with the claims file. The Board finds that VA examinations are needed in connection with the claims for service connection for a right shoulder disorder, a left shoulder disorder, a low back disorder, a cervical spine disorder, an acquired psychiatric disorder, GERD, TBI, headaches, left hand tremor, a dental disorder, hearing loss, tinnitus, a right ankle disorder, a right knee disorder, and a left knee disorder. The medical evidence shows that there are current diagnoses of record for many of these conditions, and the Veteran has alleged that he has experienced symptoms since service. Specifically, the Veteran has reported an in-service accident during which he injured his back, neck, tooth, shoulders, ankle, and knees. He has also indicated that, following the accident, he was treated by other medics as a part of their training because he was in a medical unit. He also testified that it was common practice for the medics to self-treat and stated that he treated himself in service. He has also provided lay statements from fellow soldiers who witnessed the accident and his injuries. In addition, the Veteran has reported that he has experienced hearing loss and tinnitus since service due to his exposure to noise. As a result of this testimony and diagnoses of record, the Board finds that VA examinations should be obtained for his claims. The Board notes that the current evidence of record does not appear to show a diagnosis of hearing loss, an acquired psychiatric disorder, TBI, headaches, or a hand tremor. However, in light of his testimony that he self-treated, as well as the other lay statements, the Board finds that VA examinations should also be obtained for these disorders. The Board further finds that the Agency of Original Jurisdiction (AOJ) should attempt to verify the Veteran’s stressors on remand. Accordingly, the case is REMANDED for the following action: 1. The AOJ should request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for his back, psychiatric disorder, GERD, TBI, headaches, right shoulder, left shoulder, left hand tremor, cervical spine, dental disorder, bilateral hearing loss, tinnitus, right ankle, right knee, and left knee. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. Any outstanding VA medical records should also be obtained and associated with the claims file. 2. The AOJ should then take all appropriate steps to verify the Veteran’s claimed stressors. If any records are classified, the AOJ should properly document the file and determine if any additional development can be conducted to generally confirm whether a stressor occurred (even if the details cannot be furnished). 3. After the above development has been completed, the Veteran should be afforded a VA examination to determine the nature and etiology of any low back or cervical spine disorder that may be present. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran’s service treatment records, post-service medical records, and assertions. The examiner should note that the Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the appellant, the examiner should provide a fully reasoned explanation. The examiner should opine as to whether it is at least as likely as not that the Veteran has a current low back and/or cervical spine disorder that is causally or etiologically related to his military service, to include any injury or symptomatology therein. The examiner should specifically address the Veteran’s statements regarding the in-service accident and his testimony that his current back disorder is also related to carrying heavy equipment while in service, as well as medical records noting the presence of a September 2004 motor vehicle accident, scoliosis of the spine, and a civilian job injury in December 2010. (The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of a certain conclusion as it is to find against it.) A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important “that each disability be viewed in relation to its history [,]” 38 C.F.R. § 4.1, copies of all pertinent records in the appellant’s claims file, or in the alternative, the claims file, must be made available to the examiner for review. 4. After the above development has been completed, the Veteran should be afforded a VA examination to determine the nature and etiology of any right and left shoulder disorders that may be present. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran’s service treatment records, post-service medical records, and assertions. The examiner should note that the Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the appellant, the examiner should provide a fully reasoned explanation. The examiner should opine as to whether it is at least as likely as not that the Veteran has a current left or right shoulder disorder that is causally or etiologically related to his military service, to include any injury or symptomatology therein. The examiner should specifically address the Veteran’s statements regarding the in-service accident in his or her opinion. (The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of a certain conclusion as it is to find against it.) A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important “that each disability be viewed in relation to its history [,]” 38 C.F.R. § 4.1, copies of all pertinent records in the appellant’s claims file, or in the alternative, the claims file, must be made available to the examiner for review. 5. After the above development has been completed, the Veteran should be afforded a VA examination to determine the nature and etiology of any right ankle disorders that may be present. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran’s service treatment records, post-service medical records, and assertions. The examiner should note that the Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the appellant, the examiner should provide a fully reasoned explanation. The examiner should opine as to whether it is at least as likely as not that the Veteran has a current right ankle disorder that is causally or etiologically related to his military service, to include any injury or symptomatology therein. The examiner should specifically address the Veteran’s statements regarding the in-service accident and his testimony that he sprained his ankle several times while in service. (The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of a certain conclusion as it is to find against it.) A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important “that each disability be viewed in relation to its history [,]” 38 C.F.R. § 4.1, copies of all pertinent records in the appellant’s claims file, or in the alternative, the claims file, must be made available to the examiner for review. 6. After the above development has been completed, the Veteran should be afforded a VA examination to determine the nature and etiology of any right and/or left knee disorders that may be present. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran’s service treatment records, post-service medical records, and assertions. The examiner should note that the Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the appellant, the examiner should provide a fully reasoned explanation. The examiner should opine as to whether it is at least as likely as not that the Veteran has current right or left knee disorders that are causally or etiologically related to his military service, to include any injury or symptomatology therein. The examiner should also opine as to whether it is at least as likely as not that the Veteran has a right or left knee disorder that is caused by or aggravated by a right ankle disorder. The examiner should specifically address the Veteran’s statements regarding the in-service accident, as well as his testimony that his current knee disorder(s) may be due to constant running and carrying heavy equipment while in service and the medical records showing a December 2010 civilian job injury. (The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of a certain conclusion as it is to find against it.) A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important “that each disability be viewed in relation to its history [,]” 38 C.F.R. § 4.1, copies of all pertinent records in the appellant’s claims file, or in the alternative, the claims file, must be made available to the examiner for review. 7. After the above development has been completed, the Veteran should be afforded a VA examination to determine the nature and etiology of GERD that may be present. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran’s service treatment records, post-service medical records, and assertions. The examiner should note that the Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the appellant, the examiner should provide a fully reasoned explanation. The examiner should opine as to whether it is at least as likely as not that the Veteran has GERD that is causally or etiologically related to his military service, to include any injury or symptomatology therein. The examiner should also opine as to whether it is at least as likely as not that the Veteran has GERD that is caused by or aggravated by any service-connected disabilities and/or an acquired psychiatric disorder. (The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of a certain conclusion as it is to find against it.) A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important “that each disability be viewed in relation to its history [,]” 38 C.F.R. § 4.1, copies of all pertinent records in the appellant’s claims file, or in the alternative, the claims file, must be made available to the examiner for review. 8. The Veteran should be afforded a VA examination to determine the nature and etiology of any hearing loss and/or tinnitus that may be present. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran’s service treatment records, post-service medical records, and assertions. The examiner should note that the Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the appellant, the examiner should provide a fully reasoned explanation. The examiner is also advised that the absence of in-service evidence of a hearing disability during service is not always fatal to a service connection claim. Evidence of a current hearing loss disability and a medically sound basis for attributing that disability to service may serve as a basis for a grant of service connection for hearing loss where there is credible evidence of acoustic trauma due to significant noise exposure in service, post-service audiometric findings meeting the regulatory requirements for hearing loss disability for VA purposes, and a medically sound basis upon which to attribute the post-service findings to the injury in service. The examiner should provide an opinion as to whether it is at least as likely as not that any current hearing loss and/or tinnitus is causally or etiologically related to the Veteran’s military service, to include noise exposure therein. In rendering this opinion, the examiner should discuss medically known or theoretical causes of hearing loss and tinnitus and describe how hearing loss and tinnitus which result from noise exposure generally present or develop in most cases, as distinguished from how hearing loss and tinnitus develop from other causes, in determining the likelihood that current hearing loss and tinnitus were caused by noise exposure in service as opposed to some other cause. (The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of a certain conclusion as it is to find against it.) A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important “that each disability be viewed in relation to its history [,]” 38 C.F.R. § 4.1, copies of all pertinent records in the appellant’s claims file, or in the alternative, the claims file, must be made available to the examiner for review. 9. After the above development has been completed, the Veteran should be afforded a VA examination to determine the nature and etiology of any TBI, headaches, and/or hand tremors that may be present. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran’s service treatment records, post-service medical records, and assertions. The examiner should note that the Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the appellant, the examiner should provide a fully reasoned explanation. The examiner should identify any current TBI or residuals thereof, to include any headaches and hand tremors. For any diagnosis identified, the examiner should state whether it is at least as likely as not that the disorder manifested in or is otherwise related to the Veteran’s military service, including as a result of injury or any symptomatology therein. If a TBI is not found upon examination, the examiner should still provide an opinion as to any current headaches or hand tremors diagnosed and whether it is at least as likely as not that the Veteran has headaches or hand tremors that are causally or etiologically related to his military service, to include any injury or symptomatology therein. The examiner should specifically address the Veteran’s testimony regarding the in-service accident in his or her opinion. (The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of a certain conclusion as it is to find against it.) A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important “that each disability be viewed in relation to its history [,]” 38 C.F.R. § 4.1, copies of all pertinent records in the appellant’s claims file, or in the alternative, the claims file, must be made available to the examiner for review. 10. After the above development has been completed, the Veteran should be afforded a VA examination to determine the nature and etiology of any dental disorder that may be present. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran’s service treatment records, post-service medical records, and assertions. The examiner should note that the Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the appellant, the examiner should provide a fully reasoned explanation. The examiner should opine as to whether it is at least as likely as not that the Veteran has a dental disorder, such as chipped, missing, or defective teeth that can be ascribed to the Veteran’s testimony regarding his in-service motor vehicle accident with trauma to his mouth and tooth/teeth. (The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of a certain conclusion as it is to find against it.) A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important “that each disability be viewed in relation to its history [,]” 38 C.F.R. § 4.1, copies of all pertinent records in the appellant’s claims file, or in the alternative, the claims file, must be made available to the examiner for review. 11. After the above development has been completed, the Veteran should be afforded a VA examination to determine the nature and etiology of any acquired psychiatric disorder that may be present. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed, but should include psychological testing, including PTSD sub scales. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran’s service treatment and personnel records, post-service medical records, lay statements and assertions, and any information pertaining to the claimed in-service stressor. The examiner should note that the Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the appellant, the examiner should provide a fully reasoned explanation. The examiner should identify all current psychiatric disorders. In so doing, the examiner should consider the diagnoses of record and the results of any testing performed. For each disorder identified other than PTSD, the examiner should state whether it is at least as likely as not that the disorder manifested in service or is otherwise causally or etiologically related to the Veteran’s military service. Regarding PTSD, the AOJ should provide the examiner with a summary of any verified in-service stressors, and the examiner must be instructed that only these events and any stressors related to fear of hostile military or terrorist activity may be considered for the purpose of determining whether exposure to an in-service stressor has resulted in PTSD. The examiner should determine whether the diagnostic criteria to support the diagnosis of PTSD have been satisfied. If the PTSD diagnosis is deemed appropriate, the examiner should then comment upon the link between the current symptomatology and any verified in-service stressor. (The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of a certain conclusion as it is to find against it.) A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important “that each disability be viewed in relation to its history [,]” 38 C.F.R. § 4.1, copies of all pertinent records in the appellant’s claims file, or in the alternative, the claims file, must be made available to the examiner for review. 12. After completing these actions, the AOJ should conduct any other development as may be indicated by a response received as a consequence of the actions taken in the preceding paragraphs. J.W. ZISSIMOS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD B. Rideout-Davidson, Counsel