Citation Nr: 18157780 Decision Date: 12/14/18 Archive Date: 12/13/18 DOCKET NO. 16-56 942 DATE: December 14, 2018 ORDER Entitlement to an initial compensable rating for chronic diarrhea is denied. REMANDED Entitlement to service connection for a right shoulder disability is remanded. Entitlement to service connection for a right-hand disability is remanded. Entitlement to service connection for a low back disability is remanded. Entitlement to service connection for a right knee disability is remanded. Entitlement to service connection for a left knee disability 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 a psychiatric disability, to include adjustment disorder, bipolar disorder, and posttraumatic stress disorder (PTSD) is remanded. FINDING OF FACT At no point during the period on appeal has the appellant’s chronic diarrhea disability been more than mild or produced frequent episodes of bowel disturbance with abdominal distress. CONCLUSION OF LAW The criteria for entitlement to an initial compensable rating for chronic diarrhea have not been met. 38 U.S.C. §§ 1151, 5107; 38 C.F.R. § 4.114, Diagnostic Code 7319. REASONS AND BASES FOR FINDING AND CONCLUSION The appellant served on active duty in the United States Army from October 1978 to October 1982 and from November 1986 to February 1988. This case comes before the Board of Veterans’ Appeals (Board) on appeal from an August 2015 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO) which granted service connection for chronic diarrhea and assigned an initial noncompensable rating, effective March 14, 2015, and which denied service connection for a right shoulder disability, a right-hand disability, a low back disability, a right knee disability, a left knee disability, bilateral hearing loss, tinnitus, and a psychiatric disability, to include adjustment disorder with mixed anxiety and depressed mood, bipolar disorder, and PTSD. Entitlement to an initial compensable rating for chronic diarrhea is denied. The appellant contends that his service connected chronic diarrhea is entitled to an initial compensable rating. After a review of the record, the Board finds that the preponderance of the evidence is against the assignment of a compensable rating for any of the period on appeal. Disability evaluations are determined by the application of a schedule of ratings, which is based on the veteran’s average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. The basis of disability evaluations is the ability of the body to function under the ordinary conditions of daily life, including employment. Evaluations are based upon lack of usefulness of the part or system affected, especially in self-support. 38 C.F.R. § 4.10. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability is resolved in favor of the Veteran. 38 C.F.R. § 4.3. In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where, as here, a claimant appeals the initial rating assigned following an award of service connection, evidence contemporaneous with the claim for service connection and with the rating decision granting service connection would be most probative of the degree of disability existing at the time that the initial rating was assigned and should be the evidence “used to decide whether an [initial] rating on appeal was erroneous...” Fenderson v. West, 12 Vet. App. 119, 126 (1999). If later evidence obtained during the appeal period indicates that the degree of disability increased or decreased following the assignment of an initial rating, “staged” ratings may be assigned for separate periods of time based on facts found. Fenderson v. West, 12 Vet. App. 119, 126 (1999). The appellant’s chronic diarrhea has been rated by analogy to irritable colon syndrome (spastic colitis, mucous colitis, etc.), as there is no Diagnostic Code specifically for chronic diarrhea. 38 C.F.R. § 4.20. Under the Diagnostic Code for irritable colon syndrome, a 30 percent disability rating is assigned for severe irritable colon syndrome producing diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress. A 10 percent disability rating is assigned for moderate irritable colon syndrome producing frequent episodes of bowel disturbance with abdominal distress. A noncompensable rating is assigned for mild irritable colon syndrome producing disturbances of bowel function with occasional episodes of abdominal distress. 38 C.F.R. § 4.114, Diagnostic Code 7319. The appellant’s VA treatment records prior to his May 2015 VA examination reveal no reports of symptoms of chronic diarrhea or abdominal distress. They neither detail any treatment for chronic diarrhea, nor record any prescription of medication for chronic diarrhea. At VA treatment appointments in October 2010, May 2012, and October 2014, the appellant was asked whether he was experiencing any gastrointestinal symptoms, at which point he is recorded as having denied any symptoms of regular or chronic diarrhea, or episodes of abdominal distress. The appellant was diagnosed with chronic diarrhea in a March 2015 private medical opinion offered by a “diagnostic consultant.” The consultant apparently based the diagnosis on the appellant’s report of symptoms of diarrhea since his military service. The consultant also indicated that the appellant “continues to be medicated on an ongoing basis,” although the types of medications, dosages, etc. was not specified. The consultant provided no further comment on the symptoms or severity of the appellant’s disability. The appellant underwent a VA examination in May 2015 at which he reported diarrhea 2 times a week, usually 3 times a day, with stools being loose and watery. The appellant reported no instances of abdominal distress accompanying these occurrences. The appellant reported he was not taking any medication for the disability. Further, there was no evidence suggestive of significant weight loss, malnutrition, or other symptoms or pathology associated with the appellant’s disability. Since this VA examination, the appellant has received treatment through the VA health system. In pertinent part, records of this treatment show that in February 2017 and May 2017, he denied symptoms of diarrhea and abdominal distress. In September 2016, he reported symptoms of chills, diarrhea, headaches, sore throat, and a cough and was diagnosed with an upper respiratory infection. There is no indication the appellant has been prescribed any medication to treat his chronic diarrhea disability. After a review of all the evidence of record, the Board finds the preponderance of the evidence is against the assignment of an initial compensable rating, or a compensable rating for any of the period on appeal, for the appellant’s chronic diarrhea. The Board has considered the appellant’s contention that his disability should be rated higher than it currently is. The appellant is competent to report symptoms he experiences. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Board notes that while he has only once claimed that he has diarrhea twice a week, at no point during the appellate period has the appellant suggested that he experiences symptoms of abdominal distress along with his occurrences of diarrhea. Further, the Board notes that on numerous occasions when seeking treatment, the appellant has denied symptoms of chronic diarrhea. Although the Board has considered the Veteran’s May 2015 report that he experiences diarrhea twice a week, at no other point in his VA treatment records does he report this type of chronic diarrhea, or even any symptoms of recurrent diarrhea or abdominal distress. Rather, at various physical examinations, he specifically indicates that he is experiencing no gastrointestinal difficulties. There is also no probative evidence of record that indicates the appellant takes any medications or receives any treatment for his chronic diarrhea disability. The Board has considered the March 2015 report from the diagnostic consultant which notes that the Veteran is on continuous medication for chronic diarrhea. However, the Veteran’s clinical records and the VA examination report contain no indication of medication for chronic diarrhea and the Veteran himself reported at his March 2015 VA examination that he was not taking medication for his disability. The Board affords greater probative weight to the appellant’s report of no symptoms at numerous VA treatment appointments over the many years he has been treated at the VA as these statements were made in the context of receiving necessary medical treatment. The Board finds this more probative than his single report of twice weekly bouts of diarrhea, which was made in the context of an examination for the sole purpose of determining eligibility for VA benefits. The Board has also considered the March 2015 private examiner’s mistaken report that appellant was continuously medicated for this disability, despite the significant evidence to the contrary. Thus, the Board finds that the preponderance of the evidence is against finding the appellant has the frequency of symptoms he indicated at his VA examination, which would be “frequent episodes of bowel disturbances” as contemplated by Diagnostic Code 7319. Even if the appellant were experiencing frequent episodes of bowel disturbance as he has once suggested, the Board finds that there is no evidence of the appellant experiencing any abdominal distress with his episodes of diarrhea or any other manifestation which would result in impairment of earning capacity. A plain reading of the Diagnostic Code indicates that a higher rating is warranted for symptoms of frequent bowel disturbance “with” abdominal distress. 38 C.F.R. § 4.114, Diagnostic Code 7319. The use of the word “with” indicates that the regulation intended the Diagnostic Code to require both frequent bowel disturbances and abdominal distress for a higher compensable rating to be awarded. As the appellant has neither reported abdominal distress, nor has abdominal distress ever been noted on examination, the Board finds that the appellant has not reported symptoms consistent with a higher compensable rating. As such, the Board finds that the preponderance of the evidence is against a finding that the appellant has frequent episodes of bowel disturbances with abdominal distress or any other symptom not contemplated by the rating schedule. Therefore, the Board concludes that entitlement to an initial compensable rating, or an increased rating for any of the period on appeal, is not warranted. REASONS FOR REMAND 1. Entitlement to service connection for a right shoulder disability is remanded. The appellant contends that he has a right shoulder disability which is causally related to his active duty service. After a review of the evidence of record, the Board finds that remand is necessary prior to adjudicating this claim. At a January 2011 VA treatment appointment, the appellant underwent x-rays of his right shoulder which revealed evidence of degenerative joint disease. No etiology of this condition was provided at the time, nor was an onset date established. In a March 2015 private medical opinion, the appellant was diagnosed with “post traumatic residual degenerative joint disease” of the right shoulder which the examiner attributed to the appellant’s active duty military service. The appellant claimed at that time that he injured his shoulder lifting a heavy duffel bag while on active duty, and that he received treatment for the shoulder in service. However, there is no evidence that this diagnosis of “post traumatic residual degenerative joint disease” was made by review of x-ray evidence or by review of the appellant’s prior x-rays from January 2011. As such, while the appellant’s diagnosis of degenerative joint disease is established independently, the descriptors of the degenerative changes as “post traumatic” are not supported by the rationale provided. Nor is the opinion that the appellant’s right shoulder arthritis is related to his active service supported by adequate rationale, as the examiner does not explain how he concluded that an injury, alleged to have been incurred between 30 and 35 years prior, was related to a current diagnosis of arthritis. As such, the Board finds there is no adequate opinion upon which to rely in relation to this claim. As a VA examination has not been provided, and there is evidence indicating the appellant has a right shoulder disability, to include degenerative joint disease, and the appellant has provided information relating to an in-service injury of his shoulder, the Board finds that remand is necessary to obtain a VA examination and medical opinion on the etiology of the appellant’s right shoulder disability. McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). On remand, the examiner should address whether the appellant’s diagnosed degenerative joint disease is “post traumatic” or consistent with the natural aging process. 2. Entitlement to service connection for a right-hand disability is remanded. The appellant contends that he has a right-hand disability which is causally related to his active duty service. He asserts that he still experiences periodic pain and swelling in his hand due to an in-service incident where a 2x4 piece of wood fell on his hand in September 1981. X-rays at the time were negative for a fracture; however, the Board notes the appellant was later diagnosed with tendonitis in the right hand in February 1982. After a review of the evidence of record, the Board finds that further development is necessary prior to adjudicating this claim. In March 2015, the appellant underwent a private medical examination which diagnosed him with cramping in the right hand, as secondary to the appellant’s shoulder disability. The examiner did hedge this diagnosis by suggesting the appellant should undergo an MRI and nerve conduction study before providing more than an interim diagnosis. The examiner did provide an interim diagnosis of idiopathic cramping of the right hand, related to the right shoulder. No opinion was provided on whether the appellant’s current hand disability is related to his in-service diagnosis of tendonitis in the right hand. As even the diagnosis of the appellant’s disability is speculative in this case, the Board finds this opinion inadequate for purposes of granting the appellant entitlement to service connection. The appellant did undergo a VA examination for his right hand in June 2015 which found no impairment in functionality of the right hand. It was noted that the appellant reported “swelling every 2 years.” There was no loss in grip strength or range of motion; however, the appellant did state that he uses a wrist brace to support the hand more than 3 times per week. X-rays taken in July 2015 of the right hand revealed no pathology related to the appellant’s reported incident of having a 2x4 fall on his hand. The examiner did not address the issue of whether the appellant’s right-hand disability is related to his right shoulder disability. As the issue of a right shoulder disability is being remanded, the Board finds this issue must be remanded, as it is inextricably intertwined with the claim of entitlement to service connection for a right shoulder disability. Harris v. Derwinski, 1 Vet. App. 180 (1991). The Board also finds that, on remand, a VA examination should be obtained. The examiner should provide a diagnosis of the appellant’s right-hand disability, and must consider the interim diagnosis offered in the March 2015 private examination. The examiner should also provide an opinion on whether any current right-hand disability is related to his in-service diagnosis of tendonitis in the right hand. The examiner should also provide an opinion on the etiology of the appellant’s right-hand disability and should address both the appellant’s theory of direct entitlement to service connection, as well as the theory raised by the March 2015 private medical examination that the appellant’s right-hand disability is caused by, or aggravated beyond its natural progression by, his right shoulder degenerative joint disease. 3. Entitlement to service connection for a low back disability is remanded. The appellant contends that he has a low back disability related to his active service. He has asserted that he injured his back during a training exercise in service and has had continuing back pain ever since. After a review of the evidence of record, the Board finds that further development is necessary prior to adjudicating this claim. The appellant underwent a private medical examination of his lumbar spine in March 2015. At that examination, he was diagnosed, without x-ray testing, as having degenerative joint disease and osteoarthritis of the lumbosacral spine. No rationale was provided to support this conclusion. Further, the examiner found that the appellant’s arthritis was at least as likely as not related to his military service. Again, no rationale was provided to support this etiology. As no rationale was provided to support either the diagnosis of the disability or the causal relationship with the appellant’s claimed in-service injury, the Board finds this examination inadequate. Range of motion testing did indicate significant impairment in the appellant’s range of motion in the lumbar spine and as such there is an indication the appellant exhibits a current disability; however, the nature of that disability is as yet to be determined. Considering this, the Board finds that remand is necessary to obtain a VA examination and medical opinion addressing the nature and etiology of the appellant’s thoracolumbar disability. The examiner should address the appellant’s contention that he hurt his back while on military service and determine whether any current disability is related to his claimed in-service injury to his lower back. 4. Entitlement to service connection for a right knee disability is remanded. The appellant contends that he has a right knee disability that is related to a documented injury and treatment on his right knee while on active duty. After a review of the evidence of record, the Board finds that further development is necessary prior to adjudicating this claim. The appellant’s service treatment records note treatment of the appellant’s right knee in August 1981. At that time, the appellant complained of knee pain and feelings of the knee giving out on him. Examination of the joint revealed slight crepitus. The appellant underwent a private medical examination in March 2015 which diagnosed him, without x-ray evidence, with degenerative joint disease of the right knee. The examiner found this degenerative joint disease to be “accelerated” and to be the same condition for which the appellant was treated in active duty military service; however, no rationale was provided to support this opinion. There was no indication from the appellant’s service treatment records that he was diagnosed with degenerative joint disease in service. Further, as discussed below, when the appellant’s right knee was x-rayed in May 2015, there was no evidence of degenerative joint disease. As such, the Board finds the March 2015 private medical examination of the right knee inadequate, as it does not provide a sound rationale for its diagnosis or opinion on etiology. The appellant was afforded a VA examination for his right knee disability in June 2015. After an examination and x-ray testing, it was determined that the appellant was suffering from knee pain and swelling. His knee had some loss of range of motion and pain on range of motion testing. There was no objective evidence of instability in the joint after ligament testing. After reviewing the appellant’s service treatment records, the examiner determined that the appellant’s in-service injury to his right knee was probably related to retropatellar or patellofemoral pain syndrome; however, the examiner said that it would be speculation to say if the appellant’s current knee disability was related to his in-service treatment. No rationale was provided as to why it would require speculation to offer an opinion on the issue. Due to the lack of a rationale for the determination that it would require speculation to link the appellant’s current right knee pain and swelling to his in-service injury to the right knee, the Board finds this opinion inadequate. As such, the Board finds a new examination is necessary to determine the nature and etiology of the appellant’s right knee disability. The examiner should address whether the appellant’s current right knee disability is causally related to his in-service right knee injury and subsequent treatment. If the examiner determines it would require speculation to make that determination, the examiner should provide a rationale for why speculation would be necessary. 5. Entitlement to service connection for a left knee disability is remanded. The appellant contends that he has a left knee disability that is related to a documented in-service injury and treatment on his left knee while on active duty. After a review of the evidence of record, the Board finds that further development is necessary prior to adjudicating this claim. The appellant’s service treatment records note treatment of the appellant’s left knee in June 1980. The appellant reported at that time falling on his knee and experiencing significant pain. The appellant underwent a private medical examination in March 2015 which diagnosed him, without x-ray evidence, with degenerative joint disease of the left knee. The examiner found this degenerative joint disease to be “accelerated” and to be the same condition for which the appellant was treated in active duty military service; however, no rationale was provided to support this opinion. There was no indication from the appellant’s service treatment records that he was diagnosed with degenerative joint disease in service. Further, as discussed below, when the appellant’s left knee was x-rayed in May 2015, there was no evidence of degenerative joint disease. As such, the Board finds the March 2015 private medical examination of the left knee inadequate, as it does not provide a sound rationale for its diagnosis or opinion on etiology. The appellant was afforded a VA examination for his left knee disability in June 2015. After an examination and x-ray testing, it was determined that the appellant was suffering from knee pain and swelling. His knee had some loss of range of motion and pain on range of motion testing. There was no objective evidence of instability in the joint after ligament testing. After reviewing the appellant’s service treatment records, the examiner determined that the appellant’s in-service injury to his left knee was probably related to retropatellar or patellofemoral pain syndrome; however, the examiner said that it would be speculation to say if the appellant’s current knee disability was related to his in-service treatment. No rationale was provided as to why it would require speculation to offer that opinion. Due to the lack of a rationale for the determination that it would require speculation to link the appellant’s current left knee pain and swelling to his in-service injury to the left knee, the Board finds this opinion inadequate. As such, a new examination is necessary to determine the nature and etiology of the appellant’s left knee disability. The examiner should address whether the appellant’s current left knee disability is causally related to his in-service left knee injury and subsequent treatment. If the examiner determines it would require speculation to make that determination, the examiner should provide a rationale for why speculation would be necessary. 6. Entitlement to service connection for bilateral hearing loss is remanded. The appellant contends that he has bilateral hearing loss which was caused by his exposure to military noise while on active duty. The appellant asserts that he was exposed to tank engines, tank cannons, artillery fire, and other weapons fire while on active duty. After a review of the evidence of record, the Board finds that further development is necessary prior to adjudicating this claim. The appellant’s service treatment records demonstrate shifts in the appellant’s levels of hearing acuity during his period of active service, although at his two separation examinations, he did not have hearing loss which would qualify as a disability for VA purposes. See 38 C.F.R. § 3.385. The appellant underwent a private medical examination in March 2015 which diagnosed him with 30 percent hearing loss in the left ear and 40 percent hearing loss in the right ear. This examination was not conducted by a licensed audiologist and there is no indication that the appellant was afforded testing consistent with VA regulations. See 38 C.F.R. § 4.85. The examiner acknowledged that the appellant should undergo a pure tone audiogram to confirm the provided diagnosis. The examiner did opine that the appellant’s hearing loss was related to his active service; however, no medical rationale was provided to support this conclusion. Considering this, the Board finds this examination inadequate as the examination was not conducted by a certified audiologist, was not provided in a manner consistent with VA regulations with regards to hearing loss disabilities, and for failed to provide a rationale as to why the appellant’s claimed disability was related to active duty service. The appellant was afforded a VA examination in May 2015 which revealed the appellant had hearing loss for VA purposes in the left ear only. The VA examiner concluded the appellant’s left ear hearing loss was not at least as likely as not related to his active duty service because the examiner said there was no evidence of hearing threshold shifts in service. A review of the appellant’s service treatment records reveals that this is an inaccurate statement, as the appellant’s hearing shifted back and forth throughout his periods of active duty service. The examiner also failed to consider the appellant’s reports of significant military noise exposure. As the opinion relies on an inaccurate reading of the other evidence of record, the Board finds the opinion inadequate. As there is no adequate opinion of record addressing the appellant’s left ear hearing loss disability, the Board finds that a new examination is necessary to obtain an opinion on the etiology of the appellant’s left ear hearing loss disability. On remand, the examiner should address the appellant’s contentions that he was exposed to military noise from tanks, artillery, and general weapons fire while on active duty, and that this is the cause of his hearing loss, despite not having hearing loss for VA disability purposes at his separation. The examiner should also address whether the appellant’s hearing loss disability developed within one year of his separation from active service, or is otherwise related to his active service. 7. Entitlement to service connection for tinnitus is remanded. The appellant contends that he has bilateral tinnitus, which he described as “intermittent” and having been present “for a while.” After a review of the evidence of record, the Board finds that further development is necessary prior to adjudicating this claim. The appellant’s service treatment records demonstrate shifts in the appellant’s levels of hearing acuity during his period of active service, although at his two separation examinations, he did not have hearing loss which would qualify as a disability for VA purposes. See 38 C.F.R. § 3.385. The appellant underwent a private medical examination in March 2015 which diagnosed him with tinnitus and attributed this disability to the appellant’s active duty military service. The examination records neither the nature, nor onset date of the appellant’s tinnitus. Further it provided no rationale to support the conclusion that the appellant’s reported tinnitus was related to his active duty service beyond noting that the appellant reported exposure to military noise while on active duty. Considering this, the Board finds this examination inadequate. As such, the Board finds that a new VA examination and medical opinion is necessary prior to adjudicating this claim. The examiner should address the appellant’s reports of in-service noise exposure and should elicit from the appellant the onset date of his reported tinnitus symptoms. The examiner should then provide an opinion on the etiology of the appellant’s tinnitus, to include whether his disability was incurred during his active duty as due to exposure to tank and artillery fire. 8. Entitlement to service connection for a psychiatric disability, to include adjustment disorder, bipolar disorder, and PTSD is remanded. The appellant contends that he has a psychiatric disability, which he has claimed as adjustment disorder, bipolar disorder, and PTSD. After a review of the evidence of record, the Board finds that further development is necessary prior to adjudicating this claim. As an initial matter, the Board notes that the appellant was denied entitlement to adjustment disorder and bipolar disorder as a separate issue from the denial of his claim for PTSD. Reading the appellant’s claim broadly and sympathetically, the Board has considered these issues together as one claim for a psychiatric disability. See Clemons v. Shinseki, 23 Vet. App. 1, 4-5 (2009). The Board finds no prejudice to the appellant in doing so as the claim is remanded. Bernard v. Brown, 4 Vet. App. 384 (1993). Turning to the medical evidence, the Board notes that the appellant was diagnosed through the VA health system with adjustment disorder with insomnia, mixed anxiety, and depressed mood in January 2011. These records do not provide any opinion on the etiology of the appellant’s disability. The appellant did undergo a private medical examination in March 2015 which diagnosed him with PTSD; however, the Board affords this diagnosis low probative value as the examiner indicated that he was not a psychiatric practitioner, that his expertise was limited to referring patients to seek treatment from mental health professionals, and that he had no experience treating mental health symptoms himself. Further, he did not indicate that the diagnosis was made in accordance with the criteria in the Diagnostic and Statistical Manual of Mental Disorders. There was also no discussion of any stressor incident which would be the cause of the appellant’s PTSD. As such, the Board affords this diagnosis no probative weight. Further, the opinion that the diagnosed PTSD was causally related to the appellant’s active duty is also afforded no probative weight. The appellant underwent a private psychiatric examination in March 2015 which diagnosed the appellant with bipolar disorder, alcohol abuse, and cocaine abuse. The examiner found that the appellant’s onset of bipolar disorder was during his active duty service based on the appellant’s reports of experiencing “mood swings” and difficulties with anger during his military service. The examiner did not seem to consider in the rationale provided though, whether these reported symptoms were caused by the appellant’s admitted cocaine, alcohol, and marijuana abuse, which the appellant indicated began during his active service. The Board also notes that there were inconsistencies in the objective testing conducted, rendering the results invalid, which the examiner did not address in the rationale portion of the opinion. As such, the Board finds this opinion inadequate for purposes of establishing entitlement to service connection. Considering the appellant does have a diagnosis of adjustment disorder and bipolar disorder, and has made lay statements suggesting an onset of mental health symptoms during active service, the Board finds that remand is necessary to obtain a VA examination and medical opinion on the nature and etiology of the appellant’s psychiatric disability. McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). Regarding the appellant’s claim that he has PTSD, the Board notes that the RO denied the claim because the appellant had not provided any information on a specific stressor. However, at his March 2015 private examination, the appellant indicated that his in-service stressor was thoughts about the potential for “going into combat at any time.” He reported that “[b]eing in the Army is scary,” and that he was “scared, every day.” As such, on remand, the appellant should also be afforded an examination for PTSD which addresses whether this stressor is adequate to support a diagnosis of PTSD. On remand, the examiner should address the appellant’s two diagnosed mental health conditions, adjustment disorder and bipolar disorder, and provide an onset date for these disabilities. The examiner should also address the appellant’s substance abuse disorders and whether symptoms of more than 30 years of substance abuse are distinguishable from the appellant’s diagnosed psychiatric disabilities. The matters are REMANDED for the following action: 1. Obtain the appellant’s VA treatment records for the period from May 2017 to the present. 2. Schedule the appellant for an examination by an appropriate clinician to determine the nature and etiology of any right shoulder disability, to include degenerative joint disease. The examiner must opine whether it is at least as likely as not related to an in-service injury or disease, including the appellant’s reports of hurting his shoulder lifting a heavy duffel bag. The examiner should address whether it at least as likely as not the appellant’s right shoulder degenerative joint disease (1) began during active service, (2) manifested within one year after his discharge from service, or (3) was noted during service with continuity of the same symptomatology since service. 3. Schedule the appellant for an examination by an appropriate clinician to determine the nature and etiology of any right-hand disability. Diagnostic testing should be completed as deemed appropriate. The examiner must opine whether it is at least as likely as not related to an in-service injury or disease, including an incident documented in the appellant’s service treatment records involving a 2x4 piece of lumber falling on his hand and his later diagnosis of tendonitis of the right hand. The examiner should also address whether it is at least as likely as not that the appellant’s right-hand disability, to include reports of swelling and cramping, is (1) proximately due to the appellant’s right shoulder degenerative joint disease or (2) aggravated beyond its natural progression by that disability. 4. Schedule the appellant for an examination by an appropriate clinician to determine the nature and etiology of any low back disability. Diagnostic testing should be conducted to determine whether the appellant has arthritis of the thoracolumbar spine. The examiner must opine whether it is at least as likely as not that any disability found is related to an in-service injury or disease, including the appellant’s report of hurting his back during training. If the appellant is diagnosed with arthritis of the thoracolumbar spine the examiner should address whether it at least as likely as not (1) began during active service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service. 5. Schedule the appellant for an examination by an appropriate clinician to determine the nature and etiology of any right and left knee disabilities. Diagnostic testing should be completed if deemed appropriate. The examiner must opine whether it is at least as likely as not the appellant’s right and left knee disabilities are related to an in-service injury or disease, including separate in-service reports of knee pain. If arthritis is diagnosed, examiner should address whether the appellant’s right or left knee arthritis at least as likely as not (1) began during active service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service. The examiner should also address the prior VA medical opinion on these disabilities, which suggested the appellant’s in-service injuries were a manifestation of retropatellar or patellofemoral pain syndrome, but finding it would be speculation to conclude the appellant’s current disability is related to that diagnosis. 6. Schedule the appellant for an examination by an appropriate clinician to determine the nature and etiology of any hearing loss and tinnitus. The examiner must opine whether it is at least as likely as not related to an in-service injury disease, including the appellant’s assertion that he was exposed to tank engines, tank fire, artillery fire, and general weapons fire while on active duty. In rendering an opinion, the examiner should address the appellant’s in-service shifts in hearing acuity and whether they represent an onset of hearing loss or tinnitus. The examiner should also address whether the appellant’s hearing loss disability, while not incurred during active service, is still otherwise related to service. The examiner should also elicit from the appellant information on the onset and nature of his tinnitus symptoms. The examiner should address whether the appellant’s hearing loss or tinnitus at least as likely as not (1) began during active service, (2) manifested within one year after discharge from service, or (3) were noted during service with continuity of the same symptomatology since service. 7. Schedule the appellant for a psychiatric examination to determine the nature and etiology of any current psychiatric disability, to include posttraumatic stress disorder (PTSD), adjustment disorder, or bipolar disorder. Diagnostic testing should be completed if deemed necessary. If the appellant is diagnosed with PTSD, the examiner must explain how the diagnostic criteria are met and opine whether it is at least as likely as not related to a verified in-service stressor, to include the appellant’s reports of having been afraid that he would be sent into combat at any time. If any other acquired psychiatric disorders are diagnosed, to include adjustment disorder or bipolar disorder, the examiner must opine whether each diagnosed disorder is at least as likely as not related to an in-service injury, event, or disease, to include the appellant’s report of mood swings and anger outbursts while on active service. In addressing the appellant’s psychiatric disabilities, the examiner should address the appellant’s reports that he began abusing alcohol, cocaine, while he was on active duty, and that he started abusing marijuana prior to his entrance into active duty. To the extent possible, the examiner should differentiate between symptoms related to the appellant’s substance abuse disorders and any diagnosed psychiatric disabilities. K. Conner Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD K. Kleponis, Associate Counsel