Citation Nr: 18157868 Decision Date: 12/13/18 Archive Date: 12/13/18 DOCKET NO. 16-46 706 DATE: December 13, 2018 REMANDED Entitlement to service connection for chronic fatigue syndrome is remanded. Entitlement to service connection for bronchitis is remanded. Entitlement to service connection for asthma is remanded. Entitlement to service connection for chronic obstructive pulmonary disease is remanded. Entitlement to service connection for sleep apnea is remanded. Entitlement to service connection for hypercholesterolemia is remanded. Entitlement to service connection for hypertension is remanded. Entitlement to service connection for diverticulosis is remanded. Entitlement to service connection for colon polyps is remanded. Entitlement to service connection for kidney stones is remanded. Entitlement to service connection for cysts and lumps is remanded. Entitlement to service connection for facial acne is remanded. Entitlement to service connection for headaches is remanded. Entitlement to service connection for depression is remanded. Entitlement to an initial rating in excess of 50 percent for posttraumatic stress disorder (PTSD) is remanded. REASONS FOR REMAND The Veteran had active duty service from August 1969 to March 1971. The Veteran has reported that while he is currently enrolled in the VA healthcare system, he sees a private physician for his primary care. On enrollment in VA healthcare in May 2013, he reported that he has a private primary care physician in the Myrtle Beach area who treats him for his claimed disabilities. To date, the records associated with the Veteran’s private medical treatment have not been obtained. VA has a duty to assist a claimant in obtaining private treatment records pertinent to a pending claim. See 38 U.S.C. § 5103A. Therefore, remand is required to obtain this pertinent medical evidence. Next, the Veteran has reported that the symptoms associated with his service-connected PTSD have increased in severity since his most VA examination. Review of the record indicates his most recent VA examination was in June 2015, over four years ago. Though a layperson, the Veteran is competent to testify regarding such observable symptomatology as a depressed mood and other psychiatric symptoms. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). Where the record does not adequately reveal the current state of the claimant’s disability, the fulfillment of the statutory duty to assist requires a thorough and contemporaneous medical examination. See 38 U.S.C. § 5103A(d); Chotta v. Peake, 22 Vet. App. 80, 84 (2008). Therefore, remand to afford the Veteran a current VA psychiatric examination is warranted. The matters are REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for his private primary care provider. Make two requests for the authorized records from this provider, unless it is clear after the first request that a second request would be futile. (Continued on the next page)   2. Schedule the Veteran for a VA psychiatric examination to assess the current nature and severity of his service-connected PTSD. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. To the extent possible, the examiner should identify any symptoms and functional impairments due to PTSD alone and discuss the effect of the Veteran’s psychiatric disability on any occupational functioning and activities of daily living. The entire claims file, including a copy of the remand, should be made available to, and be reviewed by, the VA examiner. All appropriate tests, studies, and consultation should be accomplished and all clinical findings should be reported in detail. Thomas H. O'Shay Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Thomas D. Jones, Counsel