Citation Nr: 18156300 Decision Date: 12/11/18 Archive Date: 12/07/18 DOCKET NO. 16-57 709 DATE: December 11, 2018 REMANDED Entitlement to service connection for a prostate condition, to include as secondary to herbicide agent exposure, is remanded. Entitlement to service connection for an acquired psychiatric disorder is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from February 1970 to October 1971 including service in the Republic of Vietnam for which he was awarded the Combat Infantryman Badge. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a July 2016 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran’ s claim of entitlement to service connection for posttraumatic stress disorder (PTSD) has been recharacterized as reflected above to include consideration of all psychiatric disorders reasonably raised by the record. Clemons v. Shinseki, 23 Vet. App. 1 (2009). 1. Entitlement to service connection for a prostate condition is remanded. An examination is required to address the Veteran’s prostate claim. His exposure to herbicide agents during active duty is conceded based on his Vietnam service. To date, the Veteran has not been afforded a prostate examination because the RO found that he did not have prostate cancer. However, VA treatment records note the Veteran had a prostate-specific antigen (PSA) of 13 in 2010 and a PSA of 31 in March 2016, which was described by E.H., M.D. as “very significantly elevated.” While the presence of a high PSA is not a diagnosis, it is symptomatic and triggers the VA’s duty to examine the Veteran. Additionally, private treatment records from June 2016 show that the Veteran was diagnosed with benign prostatic hyperplasia for which a transurethral resection of the prostate was performed. It is unclear if this is a diagnosis for a disorder or a symptom of an associated condition, but an examination is required to determine if the Veteran has a current prostate diagnosis and whether that diagnosis is related to his service, including his conceded exposure to herbicide agents in Vietnam. McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). 2. Entitlement to service connection for an acquired psychiatric disorder is remanded. Regarding the Veteran’s acquired psychiatric disorder, the June 2016 examination report is inadequate, as the examiner did not provide a sufficient rationale. Specifically, the examiner provided no rationale for her determination that the Veteran’s psychiatric disorder was not due to Vietnam trauma and discounted the Veteran’s report that he was a scout in Vietnam and noted that his DD Form 214 did not support this assertion. See June 2016 VA Examination. The Veteran’s service personnel records clearly demonstrate that he served as a scout from July 1970 to August 1971, the entire time he was in Vietnam. As the examiner based her findings, at least in part, on the inaccurate factual premise, the examination is without probative value. As a result, a new VA examination is necessary to determine the nature and etiology of the Veteran’s psychiatric disability on remand. Any outstanding treatment records should also be secured. The matters are REMANDED for the following action: 1. Obtain all outstanding VA treatment records. 2. With any necessary assistance from the Veteran, obtain any outstanding relevant private treatment records, to include any records from urologist S.L., M.D., and Newton-Wellesley Hospital. 3. Then schedule the Veteran for a VA examination to determine the nature and etiology of the Veteran’s prostate disability. The claims file must be made available to the examiner, and the examiner must specify in the examination report that the entire record has been reviewed. All necessary tests and studies should be conducted and all findings reported in detail. Following review of the claims file, the examiner should address the following: (a.) Please indicate whether the Veteran has prostate cancer. (b.) For any prostate disability other than cancer diagnosed, please state whether it is a least as likely as not (50 percent or greater probability) that the such disability had its onset in or is otherwise related to service, to include the Veteran’s conceded exposure to herbicide agents in the Republic of Vietnam. Please do not rely solely on the absence of documentation in the service treatment records, or the fact that the specific disability is not one subject to presumptive service connection based on herbicide agent exposure. Please support all opinions with robust rationale, and if unable to opine, provide reasoning for that conclusion. 4. Then schedule the Veteran for a VA examination with an examiner other than the June 2016 VA examiner to determine the nature and etiology of any acquired psychiatric disorder. The examiner should review the entire claims file, including a copy of this remand. All necessary tests and studies should be conducted and all findings reported in detail. Based on review of the record, and examination of the Veteran, the examiner should respond to the following: (a) Please indicate whether the Veteran meets the criteria for a diagnosis of PTSD, and if so, identify the stressor(s) upon which such diagnosis is based and whether they is/are related to his confirmed combat exposure, as reflected by his award of a Combat Infantryman Badge. (b) If a diagnosis of PTSD is not furnished, the examiner should provide a detailed discussion of why the Veteran does not meet the PTSD diagnostic criteria for that diagnosis. (c) As to each psychiatric disorder other than PTSD diagnosed, to include adjustment disorder (see June 2016 VA examination report), the examiner should opine as to whether it is at least as likely as not (50 percent or greater probability) that such disorder had its onset in service, or is otherwise related to his combat service. In addressing this question, the examiner is advised that in the case of a combat Veteran, not only is the combat injury (stressors) presumed, but also that he incurred a psychiatric disorder relative to that combat injury during service. Please consider the Veteran psychiatrically sound at service entrance, as psychiatric examination was normal at that time. A complete rationale for all opinions must be provided. If the examiner cannot provide an opinion without resorting to speculation, he or she should expressly indicate that and provide a supporting rationale as to why that is so. S. BUSH Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD G.Rouse, Associate Counsel