Citation Nr: 18154077 Decision Date: 11/29/18 Archive Date: 11/28/18 DOCKET NO. 09-07 342 DATE: November 29, 2018 REMANDED Entitlement to service connection for a left ankle disability is remanded. Entitlement to service connection for a heart disability is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1973 to November 1973. This matter comes before the Board of Veterans’ Appeals (Board) from a September 2007 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The matter has been remanded to the Board from a July 2018 joint motion for remand from the Court of Appeals for Veterans Claims (CAVC). The Veteran declined a hearing in a VA Form 9 appeal submitted February 2009. The Board must provide a medical examination or obtain a medical opinion when necessary to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). An examination is necessary when there is: (1) evidence of a current disability, or recurrent symptoms of a disability; (2) evidence establishing an in-service injury or disease occurred that would support incurrence or aggravation; (3) an indication that the current disability may be related to the in-service event; and (4) insufficient evidence to decide the case. Id.; 38 C.F.R. § 3.159(c)(4). When VA undertakes to provide an examination or opinion it must ensure that the examination or opinion provided is adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). A VA medical examination or opinion is adequate where it is: (1) based upon consideration of the Veteran’s prior medical history and examinations, (2) describes the disability in sufficient detail so that the Board’s evaluation of the claimed disability will be fully informed, and (3) sufficiently informs the Board of a medical expert’s judgment on a medical question and the essential rationale for that opinion. Stefl v. Nicholson, 21 Vet. App. 120 (2007). Monzingo v. Shinseki, 26 Vet. App. 97 (2012). See Acevedo v. Shinseki, 25 Vet. App. 286, 293 (2012) (“[A]n adequate medical report must rest on correct facts and reasoned medical judgment so as [to] inform the Board on a medical question and facilitate the Board’s consideration and weighing of the report against any contrary reports.”). 1. Entitlement to service connection for a left ankle disability is remanded. The Veteran asserts that he injured his ankle during a field exercise while on active duty, and was taken by ambulance to the hospital. In-service medical records indicate that a left ankle injury. The Veteran reports that his ankle still bothers him. A July 2015 VA examination of the Veteran’s left ankle stated that there were indications of remote trauma, but that the soft tissues were currently unremarkable. It went on the state that there was mild limitation of motion, but that this did not contribute to a functional loss. The examiner opined that any conclusions reached as to functional limitations during a flare-up would be speculation. This examination is inadequate because it is unclear from the examination whether the Veteran has a current left ankle disability. The examiner listed a diagnosis of strain of the left ankle and a date of diagnosis of 1973. However, the examiner later found that the in-service ankle strain resolved. If the examiner is stating that the Veteran does not have a current left ankle disability, this appears to conflict with other portions of the examination which noted an abnormal x-ray, functional loss, and occasional use of a brace. This lack of clarity relating to the Veteran’s history and whether he has a current left ankle disability renders the VA examiner’s opinion insufficient. 2. Entitlement to service connection for a heart disability is remanded. The Veteran asserts that he has heart pain since shortly after he enlisted. He states that he had an elevated heart rate and chest pain during PT and after being sent into a gas chamber for training. He reports that these pains lasted for several days, which the Veteran reports was at the time diagnosed as chest wall pain, unrelated to his heart. There is a July 1973 medical report of chest pain, but there are no indications of a cause or diagnosis in the medical reports on record. The Veteran reports that a physician has told the Veteran that he believes that this was a misdiagnosis. The July 2015 VA examination of the Veteran’s heart reported diagnoses of heart conditions dating to 1997, but did not offer any kind of opinion as to whether these conditions were at least as likely as not related to the Veteran’s service. This examination was inadequate because it inaccurately characterized treatment records from 1973 and 1977. The VA examiner stated that the Veteran “was seen in 1973 for chest pain that was not diagnosed as cardiac in origin. Normal heart evaluation; normal chest x-ray; treated with cough medication. Normal medical evaluation in 1977.” The record does not appear to contain a chest x-ray from 1973. There is a July 1973 service treatment record that does not have an x-ray notation. There is also a July 1977 report of medical examination for re-enlistment (after service), which does show a normal chest x-ray. The July 2015 VA opinion therefore does not appear to contain a correct recitation of the Veteran’s history, and is therefore inadequate. The matters are REMANDED for the following action: 1. Request any outstanding VA and private treatment records pertaining to the claims remanded herein. All attempts to secure this evidence must be documented. 2. Schedule an examination by an appropriate clinician to determine the existence of any left ankle disability. The claims file, including the Veteran’s lay statements, must be made available to the examiner. (a.) The examiner should clearly state whether any left ankle disability is as likely as not (i.e., a probability of 50 percent or greater) related to an in-service injury or disease. (b.) The examiner should specifically address a finding from a March 2015 VA x-ray report which showed “a small corticated density seen distal to the medial malleolus likely related to remote trauma.” 3. Schedule an examination by an appropriate clinician to determine the nature and etiology of any heart disability. The claims file, including the Veteran’s lay statements, must be made available to and be reviewed by the examiner. The examiner should determine whether the Veteran had a heart disability during service or whether any heart disability is related to service.   4. If upon completion of the above action the claim remains denied, the case should be returned to the Board. H. N. SCHWARTZ Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S.W. Strike, Associate Counsel