Citation Nr: 18154511 Decision Date: 12/04/18 Archive Date: 11/30/18 DOCKET NO. 15-06 694 DATE: December 4, 2018 REMANDED The issue of entitlement to service connection for a psychiatric disability, to include posttraumatic stress disorder (PTSD) and an anxiety disorder, is remanded. The issue of entitlement to service connection for hypertension is remanded. The issue of entitlement to service connection for a right knee disability to include osteoarthritis is remanded. The issue of entitlement to service connection for a left knee disability to include osteoarthritis is remanded. The issue of entitlement to service connection for a sleep disorder, to include obstructive sleep apnea and insomnia, is remanded. REASONS FOR REMAND The Veteran had active service from November 1983 to November 1992 and from January 2004 to January 2006. He had additional duty with the Air Force Reserve. The Veteran served in Afghanistan. The Veteran appeared at a July 2018 hearing before the undersigned Veterans Law Judge at the St. Petersburg, Florida, Regional Office. The hearing transcript is of record. On and after March 24, 2015, claims for Department of Veterans Affairs (VA) benefits are to be submitted on the appropriate claims form. 38 C.F.R. § 3.155. At the July 2018 Board hearing, the Veteran made contentions which may be reasonably construed as informal claims for service connection for sinus and allergic rhinitis disabilities. The Veteran should be provided with the appropriate claim form in order to submit claims for service connection for a sinus disability and allergic rhinitis if he desires. 1. The issue of entitlement to service connection for a psychiatric disability, to include PTSD and an anxiety disorder, is remanded. The Veteran asserts that service connection for PTSD is warranted secondary to multiple in service stressful events including handling the bodies of deceased fellow service personnel and seeing an Afghan warlord’s decapitated head near a United States military facility in Afghanistan. The record shows that the Veteran served in the Air Force Reserve from 1998 to 2012. The Veteran’s periods of active duty, active duty for training, and inactive duty for training with the Air Force Reserve have not been verified and all service medical documentation associated with any such duty has not been requested for association with the record. A September 2018 written statement from J. Delgado, M.D., states that he had treated the Veteran for PTSD, hypertension, osteoarthritis of the knees, sleep apnea, and insomnia since 2012. Clinical documentation of the cited private treatment is not of record. At the July 2018 Board hearing, the Veteran testified that he received ongoing PTSD treatment at the Gainesville, Florida, VA Medical Center. VA clinical documentation dated after March 2013 is not of record. VA should obtain all relevant VA and private treatment records which could potentially be helpful in resolving the Veteran’s claims. Murphy v. Derwinski, 1 Vet. App. 78 (1990); Bell v. Derwinski, 2 Vet. App. 611 (1992). The report of a July 2011 VA psychiatric examination states that the Veteran was treated for PTSD at the Gainesville, Florida, VA Medical Center. The Veteran was diagnosed with anxiety disorder. The examiner commented that “the Veteran does not meet the criteria for PTSD” and “at this point, it is less likely as not that the anxiety disorder, NOS is related to his conceded stressor of fear of hostile military or terrorist activity.” The examiner did not note or otherwise discuss the apparent conflict between the reported ongoing VA PTSD treatment and his finding that the Veteran did not meet the criteria for the diagnosis of PTSD. VA’s duty to assist includes, in appropriate cases, the duty to conduct a thorough and contemporaneous medical examination which is accurate and fully descriptive. McLendon v. Nicholson, 20 Vet. App. 79 (2006); Green v. Derwinski, 1 Vet. App. 121 (1991). When VA obtains an evaluation, the evaluation must be adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). Because of the cited deficiencies in the July 2011 VA psychiatric examination report and the documentation of ongoing VA and private PTSD treatment, the Board of Veterans’ Appeals (Board) finds that further VA psychiatric evaluation is needed. 2. The issue of entitlement to service connection for hypertension is remanded. The Veteran contends that service connection for hypertension is warranted as he was initially diagnosed with and treated for hypertension by service medical personnel. A March 2003 service medical record notes that the Veteran had been recently diagnosed with hypertension. The Veteran’s duty status in March 2003 has not yet been verified. At the July 2018 Board hearing, the Veteran testified that he had received ongoing hypertension treatment at the Gainesville, VA Medical Center and from a Dr. Bansuden. Clinical documentation of the cited private treatment is not of record. In his September 2018 written statement, Dr. Delgado indicated that “it is known that emotional distress like experiencing rocket attacks, mortuary duties with body bags and caskets … can affect blood pressure.” The Veteran has not been provided a VA hypertension examination. 3. The issues of entitlement to service connection for a bilateral knee disability, to include osteoarthritis, are remanded. The Veteran contends that service connection for right knee and left knee disabilities is warranted as he initially was diagnosed with and treated for the disabilities by service medical personnel. An April 2011 service medical record notes that the Veteran was diagnosed with arthritis of the right knee and the left knee. The Veteran’s duty status in April 2011 has not yet been verified. The report of a July 2011 VA knee examination states that the Veteran was diagnosed with right knee and left knee strain and degenerative joint disease. The examiner could not opine as to any relationship between the diagnosed knee disabilities and active service “without resorting to mere speculation.” The phrase “without resort to speculation” should indicate the limitations of knowledge in the medical community at large and not those of a particular examiner.” Jones v. Shinseki, 23 Vet. App. 382 (2010). The opinion in the July 2011 VA examination report expresses the examiner’s limitations. Therefore, the Board concludes that further VA knee evaluation is necessary to resolve the issues raised by the Veteran’s appeal. 4. The issue of entitlement to service connection for a sleep disability, to include obstructive sleep apnea and insomnia, is remanded. The Veteran contends that service connection for a sleep disability is warranted as he exhibited excessive snoring during his first deployment. A May 2010 service medical record notes that the Veteran was “seen by PCP for inadequate sleep.” The Board observes the Veteran’s duty status in May 2010 has not yet been verified. The Veteran has not been provided a VA sleep examination. The matters are REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for each private healthcare provider, including J. Delgado, M.D., and Dr. Bansuden, who has treated any psychiatric, hypertension, knee, and sleep disabilities. Make two requests for any authorized records from all identified healthcare providers unless it is clear after the first request that a second request would be futile. 2. Request that the Veteran submit copies of any records in his possession relating to dates of inactive duty for training and active duty for training. 3. Contact the National Personnel Records Center or the appropriate service entity and request verification of the Veteran’s complete periods of active duty for training and inactive duty for training with the Air Force Reserve and that all available service medical and personnel records associated with the Veteran’s service be provided for incorporation into the record. 4. Obtain the Veteran’s VA treatment records associated with treatment after March 2013, including that provided at the Gainesville, Florida, VA Medical Center. 5. Schedule the Veteran for a VA psychiatric examination with a psychologist or psychiatrist. The examiner must review the record and should note that review in the report. A rationale for all opinions should be provided. The examiner should: (a) Diagnose all psychiatric disabilities found. If PTSD is diagnosed, the examiner must identify the specific stressors upon which the diagnosis is based. The examiner should specifically state whether or not each criterion for a diagnosis of PTSD is met and if so, what stressor caused PTSD, to include whether the diagnosis is based on a fear of hostile military or terrorist activity. (b) Opine whether it at least as likely as not (50 percent probability or greater) that each identified psychiatric disability had its onset during active service or is related to any incident of service, including the Veteran’s duty in Afghanistan. 6. Schedule the Veteran for a VA hypertension examination to assist in determining the nature and etiology of diagnosed hypertension and any relationship to active service. The examiner must review the record and should note that review in the report. A rationale for all opinions should be provided. The examiner should: (a) Diagnose all hypertensive disabilities found. (b) Opine whether it is at least as likely as not (50 percent probability or greater) that any identified hypertensive disability had its onset during active service or is related to any incident of service, including the reported in-service elevated blood pressure readings. Reconcile the opinion with the other opinions of record, including from Dr. Delgado. 7. Schedule the Veteran for a VA orthopedic examination to assist in determining the current nature of any identified right or left knee disability and any relationship to active service. The examiner must review the record and should note that review in the report. A rationale for all opinions should be provided. The examiner should: (a) Diagnose all right and left knee disabilities found. (b) Opine whether it is at least as likely as not (50 percent probability or greater) that any identified right or left knee disability had its onset during active service or is related to any incident of service, including the documented knee complaints. 8. Schedule the Veteran for a VA examination with a medical doctor to assist in determining the nature and etiology of any identified sleep disability. The examiner must review the record and should note that review in the report. A rationale for all opinions should be provided. The examiner should: (a) Diagnose all sleep disabilities found, and specifically opine whether diagnoses of sleep apnea and insomnia are warranted. (b) Opine as to whether it is at least as likely as not (50 percent probability or greater) that any identified sleep disability, to include sleep apnea or insomnia, had its onset during active service or is related to any incident of service. Harvey P. Roberts Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J. T. Hutcheson, Counsel