Citation Nr: 20021047 Decision Date: 03/24/20 Archive Date: 03/24/20 DOCKET NO. 17-27 630 DATE: March 24, 2020 REMANDED Entitlement to service connection for pseudofolliculitis barbae (PFB) is remanded. Entitlement to service connection for a right shoulder disorder is remanded. Entitlement to service connection for a right foot disorder, to include hyperkeratosis of the fifth toe, is remanded. Entitlement to service connection for a left foot disorder is remanded. Entitlement to service connection for a stomach disorder, to include ulcers, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from August 1972 to August 1975. This matter comes before the Board of Veterans’ Appeals (Board) on appeal of a November 2015 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. A hearing before the undersigned Veterans Law Judge was held via videoconference in February 2020, with the Veteran and his representative present. The transcript from the hearing has been associated with the claims file. A VA examination is required when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service, or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran’s service or with another service-connected disability, but (4) there is insufficient competent medical evidence on file for the Secretary to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006). See also 38 U.S.C. § 5103A(d)(2), 38 C.F.R. § 3.159(c)(4)(i). The third prong, which requires that the evidence of record “indicate” that the claimed disability or symptoms “may be” associated with the established event, is a low threshold. McLendon, 20 Vet. App. at 83. It is not in dispute that the Veteran underwent in-service treatment for all of the above conditions. See, e.g.: Service treatment records at Nov. 13, 1972 (PFB); July 16, 1973 (PFB); Aug. 10, 1975 (shoulder); Apr. 12-30, 1973 (corn of the fifth toe of the right foot); Nov. 3, 1972, Mar. 14, 1973 (other foot conditions); Dec. 11, 1972, Jan. 5, [year not noted], Aug. 17, 1973, Jan. 9-18, 1974, Apr. 18, 1974 (stomach pain, including ulcers). However, there are no current diagnoses of any pertinent disability, because the Veteran testified that he previously avoided medical attention due to his personal religious observance. See generally Hearing Transcript at 2-5. Notwithstanding the above, the Veteran indicated a willingness to submit to a VA examination to ascertain the status of his current disabilities, see id. at 8-9. The Board determines that the Veteran is, at a minimum, entitled to a VA examination, pursuant to McLendon. The matters are REMANDED for the following action: 1. The Veteran and his representative should be given an opportunity to procure lay statements from fellow servicemembers or family members who may be able to attest to the Veteran’s conditions, as well as to identify any outstanding private or VA treatment records relevant to the claim on appeal. After obtaining any necessary authorization from the Veteran, all outstanding records should be obtained. For private treatment records, make at least two (2) attempts to obtain records from any identified sources. If any such records are unavailable, inform the Veteran and afford him an opportunity to submit any copies in his possession. For federal records, all reasonable attempts should be made to obtain such records. The Federal Circuit has held that VA’s duty to assist includes the duty to obtain VA medical records, regardless of the relevancy of those records. See Sullivan v. McDonald, 815 F.3d 786 (Fed. Cir. 2016). If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 2. After obtaining all outstanding records, schedule the Veteran for examinations of the pseudofolliculitis barbae, right shoulder, stomach, and bilateral feet, and forward the claims file, to include a copy of this remand, to the examiner. The examiner should review the entire claims file, and the report of examination should include discussion of the Veteran’s documented history and assertions. All indicated tests and studies should be accomplished and all clinical findings should be reported in detail. The examiner should clearly identify all current disabilities of the skin (i.e., pseudofolliculitis barbae), right shoulder, stomach (specifically including, but not limited to, ulcers), and bilateral feet (specifically including, but not limited to, corns of the fifth toe on the right foot). The examiner should note that pain alone, even in the absence of a diagnosis or underlying pathology, can establish a current disability for VA purposes if it results in functional impairment. Then, with respect to each such disability, the examiner should render an opinion, as to whether it is at least as likely as not (i.e., there is a 50 percent or greater probability) that the disability had onset in, or is otherwise related to service. The examiner should specifically consider the Veteran’s documented service treatment history, including but not limited to the following records: (a.) Nov. 13, 1972, July 16, 1973 (PFB) (b.) Aug. 10, 1975 (shoulder); (c.) Apr. 12-30, 1973 (corn of the fifth toe of the right foot); (d.) Nov. 3, 1972, Mar. 14, 1973 (other foot conditions); (e.) Dec. 11, 1972, Jan. 5, [year not noted], Aug. 17, 1973, Jan. 9-18, 1974, Apr. 18, 1974 (stomach pain, including ulcers). A rationale should be provided for any opinion offered. If it is not possible to provide a specific opinion regarding the above questions, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). KRISTY L. ZADORA Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Michael B. Engle, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.