Citation Nr: 18159634 Decision Date: 12/19/18 Archive Date: 12/19/18 DOCKET NO. 15-01 781 DATE: December 19, 2018 REMANDED 1. Entitlement to service connection for skin disabilities, to include scars, affecting the arms, chest, face and legs (claimed as body scars). 2. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from September 1981 to September 1985. 1. Skin Disability The Veteran filed his service-connection claim for “body scars” in February 2011. In an April 2011 statement, the Veteran contended that he has had scars and skin problems on his arms, face, chest, and trunk related to sliding 25 to 30 from down a wooden telephone pole during service. In particular, he asserted that wood made his skin area break out with sores, and doctors have expressed to him that his skin problems/scars have come from the wood injuries. There is no question the Veteran suffered injury after falling from, and sliding down a telephone pole during service. Service treatment records document that the Veteran sought emergency care and treatment after sliding down the wooden telephone pole, and that he demonstrated multiple scrapes and open wounds with splinters in both forearms, and one deep wound to his right forearm. Additionally, November 1983 service treatment records document two lacerations on the Veteran’s right hand between the third and fifth digit knuckles. The Veteran was afforded a VA scar examination in May 2011. The examiner could identify no scars of the right and left forearms or hands. The examiner did however observe 5-inch wide by 10-inch long rectangular shaped scars, with a slightly rough, raised texture on the Veteran’s bilateral anterior thighs. The examiner opined that the Veteran’s abrasion scars on his bilateral anterior thighs were less likely than not (less than 50 percent probability) caused by or the result of sliding down the telephone pole in service because there was no record of injury to his anterior thighs in service. The Veteran contends the May 2011 VA scar examination is inadequate because the examiner relied on the lack of contemporaneous medical records in forming his opinion that the Veteran’s abrasion scars on his anterior bilateral thighs are not related to sliding down the wooden telephone pole in service. See November 2018 appellate brief. The Veteran reported he developed “bumps” on his face, chest, arms, and legs after the accident, and that the bumps resulted in scars on his thigh[s]. See January 2015 VA Form 9. Notably, a November 19, 2010 VA Preventive Medicine Education Note indicates that the Veteran complained at the time of frequent skin eruptions and loss of hair on the bilateral legs, trunk and face “R/T [related to] prior injury R/T diffuse wood splinters in [the] body.” In light of the Veteran’s contentions that he had a reaction to sliding down the wood telephone pole that caused skin problems on his face, chest, arms and legs, there remains an open question as to whether the Veteran has a skin disorder, which includes his thigh scars, that resulted from the injury. On remand, a full skin examination should be administered. 2. Psychiatric Disorder In the February 2011 VA Form 21-526, the Veteran filed a claim for entitlement to service connection for an acquired psychiatric disorder, including PTSD. The Board observes that all of the medical evidence associated with the claims file utilizes the DSM-IV diagnostic criteria, which has at various times diagnosed the Veteran with PTSD and a depressive disorder. See December 2010, January 2011, and July 2011 VA psychiatry note. Effective August 4, 2014, the VA implemented use of the Diagnostic and Statistical Manual of Mental Disorders, [hereinafter DSM-5], (Am. Psychiatric Ass’n 5th ed.) (2013). 79 Fed. Reg. 45,093, 45,094 (Aug. 4, 2014). The DSM-5 applies to applications for benefits received by the VA or pending before the Agency of Original Jurisdiction (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 (Court), or the United States Court of Appeals for the Federal Circuit. 80 Fed. Reg. 14,308 (Mar. 19, 2015). As the Veteran’s appeal was initially certified to the Board in March 2015, the DSM-5 applies. Accordingly, a VA examination is necessary to determine the Veteran’s current diagnosis under the DSM-5 criteria and its relation, if any, to his military service. Additionally, the Board observes that the evidence of record contains conflicting evidence as to whether the Veteran has current diagnosis of PTSD. Such should be clarified on remand. Accordingly, the case is REMANDED for the following action: 1. Send the Veteran a letter requesting that he submit, or authorize VA to obtain on his behalf any records of private medical care pertinent to the disabilities claimed on appeal. If the Veteran so authorizes, request the Veteran’s private records. 2. Obtain updated VA treatment records, if any, dated from July 2011 to the present day. 3. Schedule the Veteran for a comprehensive VA skin examination to assess the nature and etiology of any skin disorder identified, to include scars of the forearms, hands or thighs. A copy of the claims file should be made available to, and reviewed by the VA examiner. The examiner should take a history from the Veteran as to the progression of the claimed disabilities. Upon review of the file, interview and examination of the Veteran, the examiner should respond to each of the following: a) Does the Veteran have scarring of the upper extremities, as he so attests? If so, is it at least as likely as not (50 percent or greater probability) that such scars are due to injuries sustained during service, to include splinters and scrapes incurred while sliding down a wooden telephone pole, or a hand laceration due to glass? b) Does the Veteran have any other skin disability affecting his face, chest, arms or legs? With respect to any disability identified—including scars identified on his anterior thighs—is it at least as likely as not that such disability had onset in, or is otherwise related to injuries the Veteran sustained in service, to specifically include injuries incurred when sliding down a wooden telephone pole? In providing a response, the examiner should address the Veteran’s contention that after the accident, he developed “bumps” on his face, chest, arms and legs, and that these bumps left scars on his thighs. In other words, the examiner should address the contention that his thigh scars were not directly due to abrasions incurred when sliding down the wooden pole, but appeared after suffering a skin reaction. 4. Schedule the Veteran for a VA psychiatric examination. The examiner should take a history from the Veteran and, upon review of the record and examination, address the following: a). Identify/diagnose any acquired psychiatric disorder that presently exists or that has existed during the pendency of the claim. b). Specifically state whether the Veteran meets the DSM-5 criteria for a diagnosis of PTSD at any time during the pendency of the claim. If a diagnosis is made, the stressor(s) supporting that diagnosis should be identified. c). For each assigned current diagnosis, provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the disability had onset in, or is otherwise related to his period of active duty service, to specifically include his in-service fall from a telephone pole, and the injuries sustained. In providing the above opinion, the examiner must consider the Veteran’s submitted lay statements in evidence. Responses to the medical opinions above should be supported with a clinical explanation or rationale. (Continued on Next Page) 5. Upon completion of the above, readjudicate the issues on appeal. If any benefit sought remains denied, the Veteran and his representative should be provided with a Supplemental Statement of the Case. V. Chiappetta Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD B. Mask, Associate Counsel