Citation Nr: 18158542
Decision Date: 12/17/18	Archive Date: 12/17/18

DOCKET NO. 18-50 858
DATE:	December 17, 2018
ORDER
Service connection for posttraumatic stress disorder (PTSD) is denied.
Service connection for a low back disorder is denied.
Service connection for a left knee disorder is denied.
Service connection for a right knee disorder is denied.
Service connection for gastroesophageal reflux disease (GERD) is denied.
Service connection for facial scar, bridge of nose is denied. 
A compensable rating for left hand, 5th digit fracture injury is denied.
A 10 percent rating for facial scar, left upper lip due to laceration is granted.
Entitlement to a 10 percent disability rating under 38 C.F.R. § 3.324 for multiple, non-compensable service-connected disabilities is denied.
REMANDED
Service connection for tremors of the left hand is remanded.
Service connection for tremors of the right hand is remanded.
Service connection for a psychiatric disorder other than PTSD variously characterized as generalized anxiety disorder; other specified bipolar and related disorder with mixed features; unspecified neurocognitive disorder, is remanded.
FINDINGS OF FACT
1. The probative evidence of record reflects that the Veteran does not have a current diagnosis of PTSD.
2. A low back disorder did not manifest in service and is not attributable to service.
3. A right knee disorder did not manifest in service and is not attributable to service.
4. A left knee disorder did not manifest in service and is not attributable to service.
5. GERD did not manifest in service and is not attributable to service.
6. Facial scar, bridge of nose preexisted the Veteran’s active service.
7. There was no increase in disability in the Veteran’s preexisting facial scar, bridge of nose during service. 
8. Left hand, 5th digit fracture injury is manifested by not more than painful limited motion.
9. Facial scar, left upper lip due to laceration is painful.
10. The Veteran is being awarded a 10 percent disability rating for facial scar, left upper lip due to laceration. Thus, there is no legal entitlement to a 10 percent disability rating for multiple, non-compensable service-connected disabilities under 38 C.F.R. § 3.324, for the period on appeal.
CONCLUSIONS OF LAW
1. The criteria for service connection for PTSD are not met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304, 4.125.
2. The criteria for service connection for a low back disorder are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303.
3. The criteria for service connection for a right knee disorder are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303.
4. The criteria for service connection for a left knee disorder are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303.
5. The criteria for service connection for GERD are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303.
6. Preexisting facial scar, bridge of nose was not aggravated during service. The presumption of soundness at entry does not attach. 38 U.S.C. §§ 1110, 1131, 1111, 1153; 38 C.F.R. §§ 3.303, 3.304, 3.306.
7. The criteria for a compensable rating for left hand, 5th digit fracture injury have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.10, 4.71a, Diagnostic Code 5230.
8. The criteria for a rating of 10 percent for facial scar, left upper lip due to laceration have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.10, 4.71a, Diagnostic Code 7804.
9. The criteria for a 10 percent disability rating under 38 C.F.R. 3.324 for multiple, non-compensable service-connected disabilities have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 3.324.
REASONS AND BASES FOR FINDINGS AND CONCLUSIONS
The Veteran served on active duty from November 1975 to June 1997. He appeals September and October 2017 rating decisions that denied these claims.
Service Connection
Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service or for aggravation of a preexisting injury suffered or disease contracted in line of duty. 38 U.S.C. § 1110, 1131. 
In general, to establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service - the so-called “nexus” requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009).
A preexisting injury or disease will be considered to have been aggravated by active service where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. See 38 U.S.C. § 1153; 38 C.F.R. § 3.306. Clear and unmistakable evidence (obvious or manifest) is required to rebut the presumption of aggravation where the preservice disability underwent an increase in severity during service. See 38 C.F.R. § 3.306 (b). Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during and subsequent to service. See id.  
Under 38 U.S.C. § 1153, a veteran “bears the burden of showing that his preexisting condition worsened in service” and that “[o]nce the veteran establishes worsening, the burden shifts to [VA] to show by clear and unmistakable evidence that the worsening of the condition was due to the natural progress of the disease.” See Horn v. Shinseki, 25 Vet. App. 231 (2012). Stated differently, a “veteran must initially establish only that a preexisting condition worsened during the period of active duty, and at that point the veteran has the benefit of the presumption of aggravation.” See Smith v. Shinseki, 24 Vet. App. 40 (2010). If VA cannot show by clear and unmistakable evidence that the worsening of the preexisting condition was due to the natural progress of the disease, then “the increase is presumed to have been caused by active duty service.” See id.  
1. PTSD
The Veteran contends he has PTSD due to in-service incidents that distressed him. The issue for the Board is whether the Veteran has PTSD that began during service or is at least as likely as not related to service. 
Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. 4.125 (a); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. 3.304 (f).
The provisions of 38 C.F.R. 3.384, 4.125, 4.126, 4.127, and 4.130 were updated via a final rule, effective August 4, 2014, in part to substitute references to the DSM-IV for the DSM-5. The changes are applied to applications for benefits received by VA or pending before the AOJ on or after August 4, 2014, but not to claims certified to or pending before the Board, the United States Court of Appeals for Veterans Claims, or the United States Court of Appeals for the Federal Circuit. The Board notes that the appellant’s case was certified to the Board after the effective date of the final rule. Thus, the Board will refer to the DSM-5 criteria herein.
As will be discussed below, service connection for PTSD is being denied due to the absence of a diagnosis of PTSD. Therefore, the Board will only address the element of service connection that is missing, i.e., competent evidence of a current disability. 38 C.F.R. 3.304 (f).
The existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C. 1110; see Degmetich v. Brown, 104 F.3d 1328, 1332 (1997) (holding that interpretation of 38 U.S.C. 1110 and 1131 as requiring the existence of a present disability for VA compensation purposes cannot be considered arbitrary). In the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992).
Both VA treatment records and service treatment records (STRs) are devoid of complaints or diagnosis of PTSD. The Veteran filed this claim in March 2017. A February 2017 report from chiropractor P.J.Y., contains his opinion that the Veteran has PTSD related to service, but also provides that the Veteran will be evaluated for PTSD by the appropriate mental health professional for PTSD. Dr. Y. offered that his expertise insofar as PTSD is concerned is the recognition of the same for the purposes of referral to the appropriate specialist. A subsequent February 2017 Disability Benefits Questionnaire (DBQ) completed by W.J.A., Psy.D. shows that the Veteran does not have a diagnosis of PTSD but rather has other psychiatric diagnoses to include generalized anxiety disorder; other specified bipolar and related disorder with mixed features; unspecified neurocognitive disorder. 
There are no other treatment or examination records with regard to PTSD.  
The Board does not find that Dr. Y.’s assessment of PTSD was an actual diagnosis inasmuch as the psychiatric evaluation in the follow-up DBQ shows no diagnosis of PTSD was made. It is clear that Dr. Y.’s assessment was in essence a referral to an appropriate mental health care provider for an opinion, as explained in his report. 
Therefore, there is no diagnosis of PTSD in accordance with 38 C.F.R. 4.125 (a) at any time during the appeal or proximate to the service connection claim. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); see also Romanowsky v. Shinseki, 26 Vet. App. 289, 321 (2013).
The Board recognizes the Veteran’s belief that he has PTSD. The Veteran is competent to attest to lay-observable symptomatology; however, they are not competent to diagnose PTSD. Jandreau v. Nicholson, 492 F. 3d 1372, 1377 (Fed. Cir. 2007); Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). In a claim of service connection for PTSD, there is a legal requirement that the diagnosis of PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. 4.125, that is, a diagnosis that conforms to the DSM-5. 38 C.F.R. 3.304. Accordingly, the diagnosis of PTSD is a complex medical question. The Veteran has not been shown to possess the requisite medical expertise or knowledge to diagnose PTSD in accordance with the DSM-5. Therefore, his statements regarding PTSD are not considered competent and are not probative as to whether the Veteran has a diagnosis of PTSD.
As stated above, the existence of a current disability is the cornerstone of a claim for VA disability compensation. See Degmetich, 104 F. 3d at 1328. In the absence of evidence of a present disability, there can be no valid claim. Brammer, 3 Vet. App. at 225. Evidence must show that the Veteran currently has the disability for which benefits are being claimed. There is no evidence of a competent diagnosis of PTSD.
In light of the absence of a competent diagnosis of PTSD, service connection for PTSD is denied. 38 C.F.R. 3.304 (f); 4.125. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not applicable and the claim is denied. 38 U.S.C. 5107 (b); 38 C.F.R. 3.102.
2. Facial scar, bridge of nose
STRs include a November 1975 entrance physical examination showing a 1-inch scar, bridge of nose. 
Because the Veteran’s nose scar was noted at entrance, it preexisted service and the presumption of soundness does not attach. 
The Veteran currently has the nose scar. The question for the Board is whether the preexisting scar was aggravated by service. Here, aggravation cannot be conceded because the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during and subsequent to service. See 38 C.F.R. § 3.306.
In this regard, there are no complaints or treatment notations about the scar in the STRs, and the February 1997 retirement physical examination reflects no findings relevant to the scar. Clinical evaluation for identifying body marks and tattoos only noted a tattoo.
Dr. Y. indicates that the Veteran sustained injuries to the upper nose and left face below the lateral nose in service while engaging in martial arts. Dr. Y. also notes the Veteran was treated by military personnel. Dr. Y. observes that the scars of the nose and upper lip area are thick, obvious and painful to the touch. He noted that they persisted from service to today and should thus qualify for service connection.
The Board finds Dr. Y.’s opinion to be of no probative value as to aggravation because the documented treatment record is contrary to his premise that the Veteran received treatment in service for the nose bridge scar. It is contrary to the uncontroverted facts as established in the STRs. It does not acknowledge that the nose bridge scar was present prior to service. An opinion based upon an inaccurate factual premise has no probative value. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993).
Moreover, VA examination in October 2017 contains the examiner’s opinion that the nose scar pre-existed service and was not aggravated in service. The examiner cited the 1975 enlistment examination as evidence of pre-existence of the 1-inch nose bridge scar and also found no evidence of aggravation. 
The Board concludes that, while the Veteran has a 1-inch scar on the bridge of his nose, this condition preexisted service and was not aggravated by service. The Board accords substantial probative weight to the competent medical evidence, the service treatment record and the 2017 VA examiner’s opinion, which combine to show no aggravation in service. While the Veteran is competent to report having experienced certain symptoms, his assertions made are of less probative value than the medical record which shows he did have the scar prior to service which was not aggravated in service. 
While the Veteran argued that his nose bridge scar is somehow related to service, the fact that he had a preexisting scar is indisputable. Also indisputable is that there is no treatment for the scar in service, and the separation examination is negative for any suggestion of aggravation.  His lay evidence is far less probative and less credible than the contemporaneous service records.
In weighing the evidence, the Board finds that the medical evidence of record, and the lack of credible support for the Veteran’s theory, preponderates against the claim. The 2017 VA examiner’s opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Board adopts the opinion for its reasons and bases, noting that the examiner has fairly considered the material evidence of record. Wray v. Brown, 7 Vet. App. 488 (1995). Dr. Y.’s opinion is not probative as explained above.
The preponderance of the evidence weighs against this claim. Service connection is thus not warranted.
3. Low back disorderLeft knee disorder
4. Right knee disorder
5. GERD
The Veteran urges that he has low back and bilateral knee disorders, claimed as pain, as well as GERD, due to service. 
The question for the Board is whether the Veteran has these current disorders that manifested in service, or are otherwise related to service. 
The Board accepts that there is current low back and bilateral knee disorder, characterized as back and knee pain as well as GERD as demonstrated in Dr. Y.’s February 2017 medical report. 
While Dr. Y. asserts in February 2017 that the Veteran was treated for these disorders in service and they have persisted since that time, the actual STRs and post service record are contrary to this assertion. STRs are negative as to bilateral knee and back problems, and the Veteran’s retirement from service examination in February 1997 reflects normal clinical examination for the spine, lower extremities and abdomen, anus and rectum. There is no record of treatment post service for these problems either. Dr. Y.’s report in 2017 is the first medical documentation of the disorders. 
Again, Dr. Y.’s opinion is based on an inaccurate factual premise and is thus accorded no probative value as to these particular claims. 
Therefore, the preponderance of the evidence is against finding that a nexus exists between the Veteran’s low back disorder, bilateral knee disorder, or GERD, and service. 38 U.S.C. § 1110, 1131; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). Here, complaints that began years after service have not been related to service by any competent evidence. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. 
The Board gives considerable probative weight to the competent medical evidence, here the treatment record, which shows that the disorders first manifested years after service and are unrelated to service. The multi-year gap between discharge from active duty service and evidence of the disorders years later is viewed as a factor weighing against the claims. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). The weight of the evidence is against concluding that any such disease was incurred in service. 38 C.F.R. § 3.303 (d). 
Increased Rating
Disability ratings are determined by applying the criteria set forth in the VA’s Schedule for Rating Disabilities, which is based on the average impairment of earning capacity resulting from disability. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 4.1 Separate ratings may be assigned for separate periods of time based on the facts found. Hart v. Mansfield, 21 Vet. App. 505 (2007).
6. Compensable rating for left hand, 5th digit fracture injury
The Veteran seeks a compensable rating for left (minor) hand, 5th digit fracture injury, which is rated noncompensable from March 1, 2017 under Diagnostic Code (DC) 5230 for ring ot little finger limitation of motion using the Schedule of Ratings – Musculoskeletal System. 38 C.F.R. § 4.71a. Under DC 5230, any limitation of the little or ring finger, major or minor, is rated noncompensable. Although 38 C.F.R. §4.59 allows consideration of functional loss due to painful motion to be rated to at least the minimum compensable rating for a particular joint, limitation of motion under the appropriate DC is noncompensable in this case. 
The question for the Board is whether the Veteran meets or approximates the criteria for a compensable rating. For the following reasons, the Board finds that the preponderance of the evidence is against such a finding. 
The criteria for Evaluation of Ankylosis or Limitation of Motion of Single or Multiple Digits of the Hand provide a 10 percent (compensable) rating for the following:
• Amputation of the index finger through middle phalanx or at distal joint; or,
• Amputation of the long, ring or little finger without metacarpal resection, at proximal interphalangeal joint or proximal thereto; or,
• Favorable ankylosis involving the long and little fingers; or,
• Favorable ankylosis involving the long and ring fingers; or,
• Favorable ankylosis involving the ring and little fingers; or,
• Favorable ankylosis involving the thumb; or,
• Favorable or unfavorable ankylosis involving the index finger; or,
• Favorable or unfavorable ankylosis involving the long finger; or,
• Limited motion of the index or long finger: with extension limited by more than 30 degrees; or,
• Limited motion of the index or long finger: with gap of one inch (2.5 cm.) or more between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible; or,
• Limited motion of the thumb: with a gap of one to two inches (2.5 to 5.1 cm.) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers; or,
• Painful motion of two or more of the following: thumb, index finger, and long finger.
Neither the treatment record nor the examination record has demonstrated any of these factors. 
Dr. Y reported in February 2017 that the finger was hurt in service and healed with “medial (with hand in the anatomical position) deviation and flexion deformity of 20 degrees or more. The finger catches on pockets and other items causing him significant pain. The deformity also makes manipulation of hand tools very cumbersome and difficult.” 
The October 2017 VA hands examination reflects that the examiner who reviewed the claims folder and examined the Veteran found no ankylosis of the hands. The only manifestation of left hand disability was painful limitation of motion of the left little finger. Maximum extension was limited to 20 degrees for the proximal interphalangeal (PIP) joint of the left little finger as opposed to 0 degrees on the right. Also, maximum flexion was 60 for the PIP on the left and 100 on the right, and 45 degrees for the distal interphalangeal (DIP) joint on the left as opposed to 70 degrees on the right. 
Based on these findings, the criteria for a compensable rating, as set forth above, are not met or approximated. There remains no ankylosis, no gap between the thumb pad and the fingers and no amputation. 
Additionally, functional loss due to pain, fatigue, weakness, or lack of endurance, incoordination, and flare-ups, in accordance with 38 C.F.R. §§4.40 and 4.45, have been considered, but do not allow for a compensable rating under the circumstances. The VA examiner reported that the functional loss was the limited painful motion. It was noted that the Veteran did not have additional functional loss after repeated use testing. It was also noted that the injury did not impact the ability to perform occupational tasks. Dr. Y.’s description of problems related to the finger are consistent with that reasonably expected with such limited range of motion, in the Board’s lay opinion.  
The Board finds the October 2017 examination report to be thorough and well-supported. It addresses the pertinent rating criteria. Dr. Y.’s report does not provide support for a compensable rating, as it essentially describes the same level of limited range of motion. The October 2017 VA examination findings as to limitation of motion and no ankylosis are the most probative evidence as to the manifestations of the finger injury.
The preponderance of the evidence is against a compensable rating for this disability, and the claim is denied.
7. Compensable rating for facial scar, left upper lip due to laceration
The Veteran seeks a compensable rating for this scar, which is rated noncompensable from March 1, 2017 under DC 7800 for disfiguring facial scars using the Schedule of Ratings – Skin. 38 C.F.R. § 4.118 (2017). While there have been recent changes to VA’s skin ratings schedule, the Board finds this version the most favorable to the Veteran, and will assign a compensable rating for the lip scar based on criteria found in this version of the ratings.
Higher ratings for scars include a 10 percent rating for one or two scars that are unstable or painful. Three or four painful or unstable scars warrant a 20 percent rating, and five or more painful or unstable scars warrant a 30 percent rating. 38 C.F.R. § 4.118, Diagnostic Code 7804. 
The Veteran argues that his lip scar is painful, but the VA examiner in October 2017 nonetheless reported it not painful but rather was stiff when he smiled. Approximately half of the scar, an inverted Y measuring 1.5 x 0.5 cm, was observed to be covered with a mustache. 
In Dr. Y.’s examination report, the scar was described as painful to the touch, thick and obvious. 
The criteria for a 10 percent rating, and no higher, are approximated. While the VA examination reflects the scar as not painful, the Board finds that painful scarring is approximated owing to the Veteran’s ongoing contentions, those noted by Dr. Y. and the assertion that the scar pulls when he smiles. The Board finds insufficient reason to disregard the Veteran’s complaints as to the scar being painful.  
However, there is no evidence of more than two painful and unstable scars, and thus a higher rating is not warranted under DC 7804. Moreover, functional limitations are not noted, nor are two characteristics of disfigurement or visual palpable tissue loss. It is not of sufficient size to warrant a higher rating either. There are no remaining manifestations of the scar to evaluate. 
An initial rating of 10 percent is granted. An initial rating in excess of 10 percent is denied because the preponderance of the evidence is against the claim.
8. Entitlement to 10% evaluation based upon multiple, noncompensable service disabilities
Whenever a veteran is suffering from two or more separate permanent service-connected disabilities of such character as clearly to interfere with normal employability, even though none of the disabilities may be of compensable degree under the rating schedule, the rating agency is authorized to apply a 10 percent rating, but not in combination with any other rating. 38 C.F.R. § 3.324.
The application of 38 C.F.R. § 3.324 is predicated solely on the existence of non-compensable service-connected disabilities. As such, once a compensable evaluation for any such service-connected disability has been awarded, the applicability of 38 C.F.R. § 3.324 is rendered moot. See Butts v. Brown, 5 Vet. App. 532, 541 (1993). 
As stated above, the Board is awarding a 10 percent rating for the lip scar for the period in appeal. Now, the Veteran has at least one disability rating at 10 percent or more for the entire appellate period. Hence, the issue of entitlement to a 10 percent rating based upon multiple, non-compensable, service-connected disabilities is moot for the entire appellate period. See id. 
As a compensable rating under 38 C.F.R. § 3.324 requires that the claimant not be in receipt of a compensable rating for any service-connected disorder, the claim for entitlement to a 10 percent rating based on multiple, non-compensable, service-connected disabilities must be denied as a matter of law. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994).
REASONS FOR REMAND
1. Service connection for tremors of the left hand is remanded.
2. Service connection for tremors of the right hand is remanded.
Dr. Y. opined in February 2017 that the Veteran has left and right hand tremors that are related to service to include exposure to contaminants at Camp Lejeune. He does not provide any rationale for this opinion. Veterans such as this Veteran who spent 30 days or more at Camp Lejeune from August 1, 1953 to December 31, 1987 are presumed to have been exposed to volatile organic compounds (VOCs) due to contaminated drinking water. 38 C.F.R. § 3.307 (a)(7). There is a presumption that certain disabilities listed in 38 C.F.R. § 3.309 (f) are related to exposure to contaminated water at Camp Lejeune. Hand tremor is not one of the presumptive disabilities. See 38 C.F.R. § 3.309 (f). While hand tremor is not afforded presumptive service connection, a medical opinion must be obtained addressing entitlement to service connection on a direct basis. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994).
3. Service connection for a psychiatric disorder other than PTSD variously characterized as generalized anxiety disorder; other specified bipolar and related disorder with mixed features; unspecified neurocognitive disorder, is remanded.
The Veteran has current psychiatric diagnoses as set forth in Dr. A.’s aforementioned February 2017 psychiatric DBQ to include generalized anxiety disorder, other specified bipolar and related disorder with mixed features and unspecified neurocognitive disorder. While these do not include PTSD, the Veteran has asserted that his mental health problems are related to three specific incidents in his service. He detailed these incidents in a June 2017 letter to VA. Nonetheless, there is no record of the mental health issues in service nor were there ongoing treatment and complaints since service. Under the circumstances, the Board cannot make a fully-informed decision because no VA examiner has opined whether the current mental health problems are related to these reported events in service.
The matters are REMANDED for the following action:
1. Arrange for the Veteran to undergo a VA psychiatric examination by an appropriate examiner. The examiner should identify any psychiatric disorder other than PTSD, to include generalized anxiety disorder, bipolar and related disorder with mixed features, and or unspecified neurocognitive disorder, present during the pendency of this claim. 
For each diagnosed psychiatric disorder, is it at least as likely as not (a 50 percent probability or greater) that the disorder is related to or had its onset in active duty? The examiner is asked to consider the Veteran’s three reported incidents in service that he believes are the source of his mental health issues, as reported in June 2017: 
a. In July 1976 he was on a Mediterranean cruise on the USS Harlan County and he had to perform late night duties with to include climbing down a rope with a heavy pack which caused him “increased anxiety”; 
b. In May 1979 at Camp Lejeune he was completing a bridge training obstacle course he witnessed a marine being what he thought was crushed. While the marine turned out not to be hurt, the constant wonder and the likelihood of that occurring “continues to provoke negative and ongoing stressful thoughts”; 
c. In fall 1991 he was initially informed to prepare himself and his family for an impending deployment to Kuwait during the Gulf War. The fear of being deployed during a time of war caused “prominent and significant terror at that time that has never subsided”.
The examiner should provide a complete rationale for all opinions expressed.
2. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of the Veteran’s left and right hand tremor. The examiner must opine as to whether it is at least as likely as not (50% or greater probability) that any current disorder manifested by left and/or right hand tremor was caused by exposure to contaminants in the drinking water during his service at Camp Lejeune. Contaminants in the water supply means the volatile organic compounds trichloroethylene (TCE), perchloroethylene (PCE), benzene and vinyl chloride, that were in the on-base water-supply systems located at United States Marine Corps Base Camp Lejeune.
 

The examiner should provide a complete rationale for all opinions expressed.

 
H. N. SCHWARTZ
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	N. RIPPEL