Citation Nr: 18151640 Decision Date: 11/20/18 Archive Date: 11/19/18 DOCKET NO. 15-10 282A DATE: November 20, 2018 REMANDED Entitlement to service connection for an acquired psychiatric disorder to include post-traumatic stress disorder (PTSD) and Major Depressive Disorder (MDD) is remanded. Entitlement to service connection for a left knee condition is remanded. Entitlement to service connection for a respiratory disability to include allergy and sinus is remanded. Entitlement to service connection for a skin disability is remanded. Entitlement to service connection for a headache condition is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from January 1984 to June 1984 and from December 1990 to June 1991. The Veteran also had additional service in the United States Army Reserve. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from an October 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Indianapolis, Indiana. 1. Entitlement to service connection for an acquired psychiatric disorder to include post-traumatic stress disorder (PTSD) and Major Depressive Disorder (MDD). The Veteran attended a VA examination for this issue in October 2010. This examination was conducted according to the guidelines set forth under the DSM-IV; however, the Board notes that this case is governed by the DSM-V, as the matter was certified to the Board in August 2015. See Schedule for Rating Disabilities-Mental Disorders and Definition of Psychosis for Certain VA Purposes, 80 Fed. Reg. 14,308 (Mar.19, 2015) (noting that effective August 4, 2014, the diagnosis of a mental disorder must conform to DSM-5, not DSM-IV, but this change does not apply to claims that were certified for appeal to the Board on or before August 4, 2014). Thus, the Board finds that a remand is necessary in order to obtain an examination that conforms to the criteria set forth in the DSM-V. 2. Entitlement to service connection for a left knee condition is remanded. The Board notes that the Veteran attended a VA examination for this issue in August 2010. After a review of the examination, the Board finds the opinion provided by the examiner to be inadequate. The Board has reached this conclusion because the examiner did not account for the Veteran’s lay statements and then provided an analysis based on the fact that the Veteran did not exhibit a current knee disability. In addition, the Board notes that the examiner provided a medical opinion regarding the Veteran’s right knee and not the left knee which is the disability on appeal. Thus, a remand is required to obtain a more complete medical opinion as to the nature and etiology of the Veteran’s left knee disability. See 38 U.S.C. § 5103A(d) (2012); 38 C.F.R. § 3.310 (2015); Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate); Bloom v. West, 13 Vet. App. 185, 187 (1999) (a medical opinion without supporting clinical data or other rationale does not provide the required degree of medical certainty). 3. Entitlement to service connection for a respiratory disability to include allergy and sinus is remanded. The Board notes that the Veteran attended a VA examination for this issue in August 2010. After a review of the examination, the Board finds the opinion provided by the examiner to be inadequate. The Board has reached this conclusion because the examiner did not account for the Veteran’s lay statements, nor did the examiner provide a thorough and well-reasoned opinion as to why the Veteran’s condition was not caused by or related to her military service. Thus, a remand is required to obtain a more complete medical opinion as to the nature and etiology of the Veteran’s respiratory disability. See Barr, supra; Bloom, supra. 4. Entitlement to service connection for a skin disability is remanded. The Board notes that the Veteran attended a VA examination for this issue in August 2010. After a review of the examination, the Board finds the opinion provided by the examiner to be inadequate. The Board has reached this conclusion because the examiner did not account for the Veteran’s lay statements, nor did the examiner provide a thorough and well-reasoned opinion as to why the Veteran’s condition was not related to her military service. The examiner simply provided a negative nexus opinion regarding the fact that the Veteran did not exhibit a skin disability at the time of the examination. Thus, a remand is required to obtain a more complete medical opinion as to the nature and etiology of the Veteran’s skin disability. See Barr, supra; Bloom, supra. 5. Entitlement to service connection for a headache condition is remanded. The Board notes that the Veteran attended a VA examination for this issue in August 2010. After a review of the examination, the Board finds the opinion provided by the examiner to be inadequate. The Board has reached this conclusion because the examiner did not account for the Veteran’s lay statements, nor did the examiner provide a thorough and well-reasoned opinion as to why the Veteran’s condition was not caused by or related to her military service. Thus, a remand is required to obtain a more complete medical opinion as to the nature and etiology of the Veteran’s headache condition. See Barr, supra; Bloom, supra. The matters are REMANDED for the following action: 1. Contact the Veteran in order to acquire any outstanding private treatment records. 2. Obtain all outstanding VA treatment records. 3. Schedule the Veteran for an appropriate VA examination to determine the nature and etiology of any diagnosed psychiatric disabilities during the pendency of the claim on appeal according to the criteria set forth in the DSM-V. After a review of the claims file and an examination of the Veteran, the examiner should provide answers to the following questions: (A). What are the diagnoses for all of the Veteran’s current acquired psychiatric disorders? If any previously diagnosed disorder is no longer present, the examiner must provide an explanation (e.g., whether the condition was misdiagnosed, whether it dissipated, etc.). (B) As to each current psychiatric disorder, is it at least as likely as not that (50 percent or greater probability) that the psychiatric disability manifested in or is otherwise related to the Veteran’s military service, or in the case of PTSD, related to a verified stressor? (C) If PTSD is diagnosed but not found to be based on a specific stressor, is it nonetheless related to the Veteran’s fear of hostile military or terrorist activity, which involves the Veteran’s experience, witness of, or confrontation with an event or circumstance that involved actual or threatened death or serious injury, or a treat to the physical integrity of the Veteran 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 an attack upon friendly military aircraft, and the Veteran’s response to the event or circumstance involved a psychological or a physiological state of fear, helplessness, or horror. 4. Schedule the Veteran for an appropriate VA examination to determine the nature and etiology of the Veteran’s left knee disorder. The electronic claims file must be reviewed by the examiner. All indicated studies and testing must be conducted, and all pertinent symptomatology must be reported in detail. After a review of the claims file, the examiner should provide answers to the following questions: (A). Identify all left knee disorders that are currently present. (B). Is it at least as likely as not (50 percent probability or greater) that the Veteran’s left knee disorder, had its onset in service or is caused by or related at least in part to her active service? 5. Schedule the Veteran for an appropriate VA examination to determine the nature and etiology of the Veteran’s respiratory disorder. The electronic claims file must be reviewed by the examiner. All indicated studies and testing must be conducted, and all pertinent symptomatology must be reported in detail. After a review of the claims file, the examiner should provide answers to the following questions: (A). Identify all respiratory disorders that are currently present, to include an undiagnosed illness not attributable to a known clinical diagnosis. (B). Is it at least as likely as not (50 percent probability or greater) that the Veteran’s respiratory disorder, had its onset in service or is caused by or related at least in part to her active service? 6. Schedule the Veteran for an appropriate VA examination to determine the nature and etiology of the Veteran’s skin disorder. The electronic claims file must be reviewed by the examiner. All indicated studies and testing must be conducted, and all pertinent symptomatology must be reported in detail. After a review of the claims file, the examiner should provide answers to the following questions: (A). Identify all skin disabilities that are currently present, to include an undiagnosed illness not attributable to a known clinical diagnosis. (B). Is it at least as likely as not (50 percent probability or greater) that the Veteran’s skin disability, had its onset in service or is caused by or related at least in part to her active service? 7. Schedule the Veteran for an appropriate VA examination to determine the nature and etiology of the Veteran’s headache condition. The electronic claims file must be reviewed by the examiner. All indicated studies and testing must be conducted, and all pertinent symptomatology must be reported in detail. After a review of the claims file, the examiner should provide answers to the following questions: (A). Identify all headache conditions that are currently present, to include an undiagnosed illness that is not attributable to a known clinical diagnosis. (B). Is it at least as likely as not (50 percent probability or greater) that the Veteran’s headache condition, had its onset in service or is caused by or related at least in part to her active service? The Board notes that VA has been unable to locate the Veteran’s service treatment records. See May 2010 VA memorandum. Thus, the examiner clearly cannot rely exclusively on the absence of relevant treatment in the Veteran’s medical history. In providing all of the requested opinions, the examiner should consider the competent lay claims submitted by the Veteran, her friend, and family members regarding the Veteran’s conditions. The VA examination report must include a complete rationale for all opinions expressed. If the examiner feels that any of the requested opinions cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e. no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e. additional facts are required, or the examiner does not have the needed knowledge or training). Michael J. Skaltsounis Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. Rescan, Associate Counsel