Citation Nr: 18161183 Decision Date: 12/28/18 Archive Date: 12/28/18 DOCKET NO. 15-44 483 DATE: December 28, 2018 REMANDED Entitlement to service connection for low back disability is remanded. Entitlement to service connection for dizziness is remanded. Entitlement to service connection for digestive disorder to include acid reflux disease and gastritis is remanded. Entitlement to service connection for an acquired psychiatric disorder to include posttraumatic stress disorder (PTSD) (also claimed as depression) is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1976 to January 1980. These matters come to the Board of Veterans’ Appeals (Board) from a November 2011 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Detroit, Michigan. 1. Entitlement to service connection low back disability is remanded. 2. Entitlement to service connection for dizziness is remanded. 3. Entitlement to service connection for digestive disorder is remanded. Issues 1-3. The Veteran seeks service connection for a lower back disability, dizziness, and a digestive disroder. As discussed below, remand is required for additional development in these matters. In pertinent part, service treatment records corroborate that the Veteran reported back pain, dizziness, and stomach pain while in service. For instance, the Veteran stated in September 1977 that he had back pain for the last five weeks. See September 1977 STR. [Receipt Date: 09/01/2015] Then, in November 1977, the Veteran went to an emergency room because of his back pain; he was diagnosed with an H-5 strain. See November 1977 STR. [Receipt Date: 09/01/2015] Additionally, in January 1979, the Veteran complained of lower back pain. See January 1979 Medical Treatment Record. [Receipt Date: 06/19/2010] Regarding his dizziness, the Veteran reported on August 1976 that he had multiple episodes where he felt dizzy; moreover, he reported that his most recent episode caused him to pass out completely. See August 1976 STR. [Receipt Date: 09/01/2015] The Veteran elaborated by stating that he developed the sensation that he was going to vomit, he then headed to the bathroom, but passed out in the hallway prior to reaching the bathroom. Id. A total blood count and erythrocyte sedimentation rate test were conducted; the test results found that they were within normal limits. No further complaints, treatment, or diagnosis is subsequently reported in the service treatment records. The service treatment records show that the Veteran reported on multiple occasions that he suffered from stomach pains. For instance, in June 1977, the Veteran reported stomach pain. See June 1977 STR. [Receipt Date: 09/01/2015] In addition, in June 1978 the Veteran complained of stomach pains starting two weeks prior; he described the stomach pain as sharp. See June 1978 STR. [Receipt Date: 09/01/2015] Objective data included burning sensation after eating, nausea and vomiting. The medical provider assessed that the Veteran may have hyperacidity. In December 1979, the Veteran underwent an upper gastrointestinal (UGI) series radiography. See December 1979 Medical Treatment Record. [Receipt Date: 06/19/2010] The procedure revealed findings suggestive for duodenitis, but found the UGI series, which includes the esophagus and stomach, as otherwise normal. Id. A November 1979 separation examination reflects normal clinical evaluation of the spine, neurologic, abdomen and viscera. On the medical history, the Veteran reported that he had swollen or painful joins; ear, nose, or throat trouble; frequent indigestion; stomach, liver, or intestinal trouble; and recurrent back pain. The Veteran denied dizziness. In 2010, the Veteran submitted a VA claim for disability compensation. A September 2011 VA examination report reflects diagnoses for recurrent dizzy spells of unknown etiology; acid reflux disease and gastritis; and degenerative joint and disk disease, status post laminectomy surgery. The examiner opined that these conditions were not likely related to service. The medical opinion included a rationale that inappropriately relied almost exclusively on the absence of in-service evidence of documented complaints or findings to support the conclusion, and essentially dismissed the Veteran’s reported history of symptoms without any explanation. The Veteran is competent to report his experiences, injuries, and treatment. See Layno v. Brown, 6 Vet. App. 465 (1994). The examiner is not required to accept the Veteran’s theory that his military service caused his current disabilities, or that he had symptoms associated with the disabilities during or following military service if this is incongruous with the record; however, the examiner is required to fully explain why he disagreed with the Veteran’s theory of causation, and provide a discussion of the relevant or significant medical history, clinical findings, medical knowledge or literature, etc., that support the negative medical opinion or conclusion(s). Notably, in the stated rationale, the examiner did not relay what the medical evidence showed, such as the Veteran reporting that he had swollen or painful joins; ear, nose, or throat trouble; frequent indigestion; stomach, liver, or intestinal trouble; and recurrent back pain prior to separation. To ensure that VA has met its duty to assist, remand is necessary. 38 C.F.R. § 3.159(c). A medical opinion must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record. See Stefl v. Nicholson, 21 Vet. App. 102, 124-25. “[A] medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two.” Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). 4. Entitlement to service connection for an acquired psychiatric disorder is remanded. The Board finds that further development is required prior to adjudicating the Veteran’s claim. See 38 C.F.R. § 19.9. In the August 2018 appellate brief, the Veteran’s representative asserted that the Veteran’s PTSD is due to an incident occurring in May 1978 during which the Veteran’s roommate and fellow servicemember committed suicide in the apartment that they shared off-base. In elaborating, the representative stated that the Veteran reported being "shocked and horrified" upon discovering his deceased roommate on the sofa in the morning and was further traumatized when the Veteran was sent by his supervisors to clean the remains from the wall. In addition, the representative provides that the Veteran was cleared of any wrong doing after undergoing a polygraph test at the Colorado Springs Police Department. See August 2018 Appellate Brief. [Receipt Date: 08/22/2018] The Veteran’s DD Form 214 reflects that he was stationed at Fort Carson, Colorado, prior to separation in 1980. Accordingly, his active duty period in Fort Carson is verified. Post-service treatment records reflect a diagnosis for PTSD. However, further attempts to verify the Veteran’s stressor are warranted given that he has submitted a newspaper article reporting on the alleged in-service stressor. The newspaper article reports that the incident happened on May 30, 1978, at 5:00 AM at 233 E. Arada St Colorado Springs, Colorado. The record shows that the RO requested information from the United States Crime Records Center for an incident occurring on May 26, 1978; on which, the RO got a negative response. See February 2011 Third Party Correspondence. [Receipt Date: 02/25/2011]. Thus, remand is necessary to develop the alleged PTSD stressor incident. The matters are REMANDED for the following actions: 1. Obtain the Veteran’s VA treatment records for the period from May 2011 to the Present. 2. Attempt to corroborate the Veteran’s in-service stressor, to include (a) contacting the United States Crime Records Center in regards to the incident happening on May 30, 1978 at 5:00 AM at 233 E. Arada St in Colorado Springs, Colorado; and (b) obtaining the Veteran’s military pay history, which may show Basic Allowance for Housing (BAH) for off-base housing. If more details are needed, contact the Veteran to request the information. Advise the Veteran that he may submit additional lay statements that may tend to corroborate his claimed stressor(s), including the dates and locations thereof. All attempts to verify any reported PTSD stressors must be documented in the claims file. 3. Schedule the Veteran for examinations by appropriate clinicians to determine the nature and etiology of his low back, dizziness, and digestive conditions. The examiners must opine whether the disabilities are at least as likely as not related to an in-service injury, event, or disease. For the lower back disability, the examiner must opine on whether the Veteran’s degenerative joint and disk disease 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 examiners must accept the Veteran’s medical history of symptoms as truthful unless otherwise shown by the record. If any examiner rejects medical history of symptoms or problems reported by the Veteran, the examiner must explain why. A complete rationale is required to support the medical opinions rendered in these matters. 4. If there is credible necessary supporting evidence that a claimed stressor occurred, then schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any psychiatric disorder that may be present. It should be noted that the Veteran is competent to attest to factual matters of which he had first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. (a) The examiner should identify all current psychiatric disorders. He or she should specifically indicate whether the Veteran meets the criteria for a diagnosis of PTSD. (b) For each diagnosis identified other than PTSD, the examiner should state whether it is at least as likely as not (a 50 percent or greater probability) that the disorder manifested in or is otherwise related to the Veteran’s active service. (c) Regarding PTSD, the RO should provide the examiner with a summary of any verified in-service stressors, and the examiner must be instructed that only these events may be considered for the purpose of determining whether exposure to an in-service stressor has resulted in PTSD. 5. Ensure that all VA medical opinions obtained include a complete rationale for the conclusions reached. The medical opinions must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 6. Readjudicate. C.A. SKOW Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Griffey, Associate Counsel