Citation Nr: 20021389 Decision Date: 03/25/20 Archive Date: 03/25/20 DOCKET NO. 19-29 680 DATE: March 25, 2020 REMANDED Service connection for posttraumatic stress disorder (PTSD) is remanded. Service connection for hypertension is remanded. Service connection for bilateral hearing loss is remanded. Service connection for right lower extremity peripheral neuropathy is remanded. Service connection for left lower extremity peripheral neuropathy is remanded. Service connection for obstructive sleep apnea is remanded. Service connection for gastroesophageal reflux disease (GERD) is remanded. Service connection for tinea pedis is remanded. A compensable initial rating for service-connected tinea corporis is remanded. A compensable initial rating for service-connected pseudofolliculitis barbae (PFB) is remanded. REASONS FOR REMAND The appellant is a Veteran who served on active duty from February 1968 to February 1971. These matters are before the Board of Veterans’ Appeals (Board) on appeal from a July 2018 rating decision. 1. Service connection for posttraumatic stress disorder (PTSD) is remanded. Although a January 2018 VA examination indicates the Veteran did not meet the criteria for PTSD (to specifically include a finding that he has no intrusive symptoms related to his reported traumas), it does not reconcile this finding with the same examiner’s notation of continuing nightmares related to the Veteran’s time in Vietnam bunkers during mortar and other hostile attacks. Notably, the examiner conceded that the Veteran’s Vietnam stressors (which included but were not limited to those same bunker-related experiences) were related to fear of hostile military and terrorist activity. Consequently, clarification is needed. 2. Service connection for hypertension is remanded. There are virtually no post-service medical records in the Veteran’s file, but his service records show multiple notations of blood pressures that suggest some degree of elevation, particularly when compared to the American Heart Association’s (AHA’s) updated guidelines on hypertension, indicating that a diastolic pressure of 80 is “Stage I” hypertensive. Considering the above along with the fact that the Veteran is proceeding pro se and has service qualifying him for a presumption of herbicide exposure, the Board finds additional development to for medical clarification of the nature and likely cause of his claimed high blood pressure is needed. 3. Service connection for bilateral hearing loss is remanded. There is no indication upon review of the January 2018 VA audiological examination report that the examiner considered the Veteran’s service audiograms under both the current ISO-ANSI and deprecated ASA standards, which is problematic considering all service audiograms in this case were conducted in 1970 or earlier, and it is unclear which metric was used. This is notable given the examiner concluded (without much elaboration) that no significant threshold shifts occurred in service, even though a comparison of enlistment and separation audiograms seems to show some notable jumps in puretone thresholds in the right ear. It is also notable that the left ear enlistment audiogram contains confusing notations that the Board cannot decipher, warranting additional clarification from an audiologist. 4. Service connection for right lower extremity peripheral neuropathy is remanded. 5. Service connection for right lower extremity peripheral neuropathy is remanded. 6. Service connection for obstructive sleep apnea is remanded. 7. Service connection for gastroesophageal reflux disease (GERD) is remanded. Considering there are virtually no medical records in the file, his allegation that his claimed conditions are related to herbicide exposure, Vietnam service qualifying him for presumptive herbicide exposure in Vietnam, his competency to allege and report observable symptoms commonly associated with neuropathy, obstructive sleep apnea, and GERD (e.g., numbness, tingling, snoring, sleep difficulties, acid reflux, heartburn, etc.), and the fact that he is pursuing this claim pro se, the Board finds that a remand for additional development is warranted. 8. Service connection for tinea pedis is remanded. In addition to the reasons outlined above for neuropathy, sleep apnea, and GERD, all of which apply equally to his tinea pedis claim, the Board notes that a January 2018 VA skin examination report does not appear to consider whether he has tinea pedis at all, as the examination request and report focus only on pseudofolliculitis barbae and tinea corporis, without mentioning tinea pedis or the feet. Thus, medical clarification is needed.   9. A compensable initial rating for service-connected tinea corporis is remanded. 10. A compensable initial rating for service-connected pseudofolliculitis barbae (PFB) is remanded. The last examination assessing the severity of these conditions was conducted in January 2018, over two years ago, in conjunction with his original service connection claim. As capturing a current disability picture is crucial to an accurate adjudication of these claims, contemporaneous examinations are needed. The matters are REMANDED for the following action: 1. Please note that, by law, ALL remanded claims MUST be processed expeditiously. 2. Obtain all updated records (i.e., those not already of record) of VA and adequately identified private treatment the Veteran has received for the disabilities remaining on appeal. 3. Schedule the Veteran for an examination by a psychiatrist or other appropriate clinician to determine the nature and cause of any psychiatric disability. Based on a review of the record, examination of the Veteran (INCLUDING A COMPLETE SUBJECTIVE HISTORY AND REPORT DESCRIBING ONSET, COURSE, AND PROGRESSION OF HIS SYMPTOMS), and any tests or studies deemed necessary, the examiner must respond to the following: (a.) Please diagnose all psychiatric disability entities (including but not limited to PTSD) found. All diagnostic findings (or lack thereof) must be reconciled with conflicting evidence in the record. The examiner must specifically consider and discuss the significance of the Veteran’s reports of continuing nightmares about his time in Vietnam, which involved regular exposure to hostile fire that the prior VA examination concedes is consistent with fear of hostile military and terrorist activity. (b.) For each disability diagnosed, please opine as to whether it is AT LEAST AS LIKELY AS NOT (A 50 PERCENT PROBABILITY OR GREATER) that such disability is related to the Veteran’s military service, to include the conceded fear-based stressors therein. All opinions must include a detailed rationale. Providing an opinion or conclusion without enough explanation will delay processing of the claim and require further clarification. 4. Schedule the Veteran for an examination by a cardiologist or other appropriate clinician to determine the nature and cause of his claimed hypertension. Based on a review of the record, examination of the Veteran (INCLUDING A COMPLETE SUBJECTIVE HISTORY AND REPORT DESCRIBING ONSET, COURSE, AND PROGRESSION OF HIS SYMPTOMS), and any tests or studies deemed necessary, the examiner must respond to the following: (a.) Does the Veteran currently have hypertension? (b.) For each disability diagnosed, please opine as to whether it is AT LEAST AS LIKELY AS NOT (A 50 PERCENT PROBABILITY OR GREATER) that such disability is related to the Veteran’s military service, to include (but not limited to) as a result of his conceded herbicide exposure therein. The examiner must consider the significance of his blood pressure readings therein, including those at both enlistment and separation, particularly considering the AHA’s updated guidelines on hypertensive pressures. All opinions must include a detailed rationale. Providing an opinion or conclusion without enough explanation will delay processing of the claim and require further clarification. 5. Schedule the Veteran for an examination by an audiologist to determine the nature and cause of his claimed hearing loss. Based on a review of the record, examination of the Veteran (INCLUDING A COMPLETE SUBJECTIVE HISTORY AND REPORT DESCRIBING ONSET, COURSE, AND PROGRESSION OF HIS SYMPTOMS), and any tests or studies deemed necessary, the examiner must respond to the following: (a.) Does the Veteran meet the criteria for hearing loss as defined in 38 C.F.R. § 3.385? (b.) If so, is it AT LEAST AS LIKELY AS NOT (A 50 PERCENT PROBABILITY OR GREATER) that any such hearing loss is related to the Veteran’s military service, to include any noise exposure therein? The examiner must consider and discuss the significance of the puretone threshold changes in service, to include interpreting and discussing the unclear notations during his enlistment examination. The examiner must specifically consider the audiometric scores in his service records under both the ISO-ANSI and ASA standards. If the examiner feels consideration of those scores under one of these standards is inappropriate, he or she must clearly explain why. All opinions must include a detailed rationale. Providing an opinion or conclusion without enough explanation will delay processing of the claim and require further clarification. 6. Schedule the Veteran for an examination by a neurologist or other appropriate clinician to determine the nature and cause of any peripheral neuropathy found. Based on a review of the record, examination of the Veteran (INCLUDING A COMPLETE SUBJECTIVE HISTORY AND REPORT DESCRIBING ONSET, COURSE, AND PROGRESSION OF HIS SYMPTOMS), and any tests or studies deemed necessary, the examiner must respond to the following: (a.) Please diagnose all peripheral neuropathy disability entities found. All diagnostic findings (or lack thereof) must be reconciled with conflicting evidence in the record. If any previously documented diagnoses are no longer or otherwise not felt to apply, the examiner must explain why, citing to the pertinent diagnostic criteria. (b.) For each disability diagnosed, please opine as to whether it is AT LEAST AS LIKELY AS NOT (A 50 PERCENT PROBABILITY OR GREATER) that such disability is related to the Veteran’s military service, to include his conceded herbicide exposure therein. All opinions must include a detailed rationale. Providing an opinion or conclusion without enough explanation will delay processing of the claim and require further clarification. 7. Schedule the Veteran for an examination by a sleep specialist or other appropriate clinician to determine the nature and cause of his claimed sleep apnea. Based on a review of the record, examination of the Veteran (INCLUDING A COMPLETE SUBJECTIVE HISTORY AND REPORT DESCRIBING ONSET, COURSE, AND PROGRESSION OF HIS SYMPTOMS), and any tests or studies deemed necessary (including, but not limited to, a sleep study), the examiner must respond to the following: (a.) Does the Veteran meet the diagnostic criteria for sleep apnea? (b.) If so, is it AT LEAST AS LIKELY AS NOT (A 50 PERCENT PROBABILITY OR GREATER) that such disability is related to the Veteran’s military service, to include his conceded herbicide exposure therein? In addition to any sleep study results, the examiner should also consider other clinical predictors of sleep apnea, including questionnaires such as the STOP-BANG, a validated screening tool for sleep apnea (See, e.g. “STOP-Bang Questionnaire: A Practical Approach to Screen for Obstructive Sleep Apnea” published in the peer-reviewed medical journal Chest in March 2016 at 149(3):631-8 (noting 8 clinical predictors of sleep apnea, including Snoring, Tiredness during the day, Observed apnea during sleep, high blood Pressure, BMI (Body Mass Index) greater than 35 kg/m2, Age over 50 years, Neck circumference greater than 40 cm, and male Gender)). Therefore, while reviewing the claims file, the examiner should consider whether any clinical indicators of sleep apnea are now or were previously present. The examiner should identify any such clinical indicators and explain whether they might support a retrospective sleep apnea diagnosis. All opinions must include a detailed rationale. Providing an opinion or conclusion without enough explanation will delay processing of the claim and require further clarification. 8. Schedule the Veteran for an examination by a gastroenterologist or other appropriate clinician to determine the nature and cause of his claimed GERD. Based on a review of the record, examination of the Veteran (INCLUDING A COMPLETE SUBJECTIVE HISTORY AND REPORT DESCRIBING ONSET, COURSE, AND PROGRESSION OF HIS SYMPTOMS), and any tests or studies deemed necessary, the examiner must respond to the following: (a.) Does the Veteran meet the diagnostic criteria for GERD? (b.) If so, is it AT LEAST AS LIKELY AS NOT (A 50 PERCENT PROBABILITY OR GREATER) that such disability is related to the Veteran’s military service, to include his conceded herbicide exposure therein? All opinions must include a detailed rationale. Providing an opinion or conclusion without enough explanation will delay processing of the claim and require further clarification. 9. Schedule the Veteran for an examination by a dermatologist or other appropriate clinician to determine the nature and cause of his claimed tinea pedis and the current severity of his service-connected pseudofolliculitis barbae and tinea corporis. Based on a review of the record, examination of the Veteran (INCLUDING A COMPLETE SUBJECTIVE HISTORY AND REPORT DESCRIBING ONSET, COURSE, AND PROGRESSION OF HIS SYMPTOMS), and any tests or studies deemed necessary, the examiner must respond to the following: (a.) Please diagnose all skin disability entities affecting the foot found. All diagnostic findings (or lack thereof) must be reconciled with conflicting evidence in the record. If any previously documented diagnoses are no longer or otherwise not felt to apply, the examiner must explain why, citing to the pertinent diagnostic criteria. (b.) For each disability diagnosed, please opine as to whether it is AT LEAST AS LIKELY AS NOT (A 50 PERCENT PROBABILITY OR GREATER) that such disability is related to the Veteran’s military service, to include his conceded herbicide exposure therein. (c.) For each disability diagnosed, please also opine as to whether it is AT LEAST AS LIKELY AS NOT (A 50 PERCENT PROBABILITY OR GREATER) that such is CAUSED OR AGGRAVATED (WORSENED BEYOND ITS NATURAL PROGRESSION) BY his service-connected pseudofolliculitis barbae or tinea corporis. The examiner MUST ALSO describe all symptoms, pathology, and impairment associated with BOTH his service-connected tinea corporis and pseudofolliculitis barbae in enough detail to allow for application of the pertinent rating criteria. This should INCLUDE (but is not limited to) noting the percentage of total body and exposed areas affected by such conditions based on both observed on examination and subjective descriptions of the condition outside of the immediate clinical setting (e.g., during flare-ups or at other times not directly observed by the examiner) AND the types and frequency of treatment he has received for these conditions in the prior 12 months. All opinions must include a detailed rationale. Providing an opinion or conclusion without enough explanation will delay processing of the claim and require further clarification. VICTORIA MOSHIASHWILI Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Yuan, 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.