Citation Nr: 21000192 Decision Date: 01/04/21 Archive Date: 01/04/21 DOCKET NO. 16-40 758A DATE: January 4, 2021 REMANDED Entitlement to service connection for a cervical spine disability is remanded. Entitlement to service connection for a left knee disability is remanded. Entitlement to service connection for a right knee disability is remanded. Entitlement to service connection for a right ankle disability is remanded. Entitlement to service connection for a left ankle disability is remanded. Entitlement to service connection for a right eye disability is remanded. Entitlement to service connection for a sinus disability is remanded. Entitlement to service connection for a pulmonary disability, to include emphysema, is remanded. Entitlement to service connection for constipation is remanded. Entitlement to service connection for hemorrhoids is remanded. Entitlement to service connection for erectile dysfunction is remanded. Entitlement to service connection for a prostate disability is remanded. Entitlement to service connection for shingles / herpes zoster is remanded. Entitlement to service connection for pseudofolliculitis barbae is remanded. Entitlement to service connection for residuals of a cerebrovascular accident is remanded. Entitlement to service connection for a traumatic brain injury (TBI) is remanded. Entitlement to service connection for headaches is remanded. Entitlement to service connection for carpal tunnel syndrome of the left upper extremity is remanded. Entitlement to service connection for carpal tunnel syndrome of the right upper extremity is remanded. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) and substance dependence, is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1979 to March 1987. These matters are before the Board of Veterans’ Appeals (Board) on appeal from a January 2014 Rating Decision by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a Travel Board hearing before a Veterans Law Judge (VLJ) in February 2019. A transcript of that hearing has been associated with the claims file. In October 2020, the Veteran was notified that the VLJ who conducted his February 2019 hearing was no longer employed at the Board and given the opportunity to request another hearing with a different VLJ. As the Veteran did not respond within 30 days, the Board assumes that he did not want another hearing. The Board notes that the Veteran has requested that this case be advanced on the docket due to severe financial hardship. See Statement in Support of Claim received September 2020. Notably, advancement of the docket may be granted if the appellant is seriously ill or is under severe financial hardship, or if other sufficient cause is shown. 38 C.F.R. § 20.902(c). Here, the Veteran has not submitted any additional evidence in support of his motion to advance his claim on the docket, nor the does the record document the Veteran’s financial hardship. In the absence of sufficient cause, the Veteran’s motion to advance on the docket is denied. 38 C.F.R. § 20.902(c). The Veteran seeks entitlement to service connection for a cervical spine disability, a left knee disability, a right knee disability, a right ankle disability, a left ankle disability, a right eye disability, a sinus disability, a pulmonary disability (to include emphysema), constipation, hemorrhoids, erectile dysfunction, a prostate disability, shingles/herpes zoster, pseudofolliculitis barbae, residuals of a cerebrovascular accident, a TBI, headaches, carpal tunnel syndrome of the left upper extremity, carpal tunnel syndrome of the right upper extremity, and an acquired psychiatric disorder (to include PTSD and substance dependence). Unfortunately, the Board finds that additional development must be undertaken before these claims can be adjudicated on the merits. With respect to all claims, in correspondence dated in December 2019, VA requested that the Veteran complete and return an enclosed VA Form 21-4142 (Authorization to Disclose Information to VA) so that it could obtain the authorization to request treatment records from the Veteran’s private medical sources listed on a received VA Form 21-4142a (General Release for Medical Provider Information to VA). According to a Centralized Intake Coversheet dated April 23, 2020, the Veteran submitted a VA Form 21-4142 and VA Form 21-4142a via facsimile on that date; however, the three pages of attached facsimile transmissions uploaded to the claims file were illegible. It does not appear that the RO made any effort to obtain additional private treatment records after April 2020. Accordingly, the Board finds that VA’s duty to assist with respect to obtaining outstanding treatment records has not been met. On remand, legible copies of the VA Form 21-4142 and VA Form 21-4142a submitted by the Veteran on April 23, 2020, should be associated with the claims file. If legible copies of these forms do not exist, then the Veteran should be requested to resubmit the VA Form 21-4142 and VA Form 21-4142a. The RO must then attempt to obtain these records from the appropriate medical treatment providers and associate them with the claims file. With respect to the Veteran’s knee and ankle claims, the Veteran testified that he began experiencing weakness and instability in his bilateral knees and ankles in the late 1990s. The Veteran further testified as to his belief that his knee and ankle symptoms were due to the trauma associated with the 126 parachute jumps while assigned to the 1st Battalion, 508th Parachute Infantry Regiment of the 82nd Airborne Division. The Veteran’s DD Form 214 confirms that he received both a Parachute Badge and a Canadian Parachute Badge, while service personnel records confirm that he completed 3 weeks of Basic Airborne training September 1979 to October 1979 and was subsequently assigned to the 1st Battalion, 508th Infantry of the 82d Airborne. A review of the Veteran’s service treatment records reveals that he was treated for ankle sprains in March 1981 and May 1983, and that he sought treatment for pain in his bilateral lower extremities which was diagnosed as shin splints in February 1987. VA treatment records dated in June 2012 indicated that the Veteran complained of bilateral knee pain, at which time it was indicated that he had served as a paratrooper with over 100 jumps in his career. He was diagnosed as having knee arthralgia. However, the Veteran has never been provided with a VA examination relevant to his knee and ankle complaints. An examination or opinion is necessary if the evidence of record (a) contains competent evidence that the claimant has a current disability, or persistent or recurrent symptoms of disability; and (b) establishes that the veteran suffered an event, injury or disease in service; or has a presumptive disease or symptoms of such a disease manifesting during an applicable presumptive period; and (c) indicates that the claimed disability or symptoms may be associated with the established event, injury, or disease in service; but (d) does not contain sufficient medical evidence for the Secretary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4); see also McLendon v. Nicholson, 20 Vet. App. 79 (2006) (discussing the four elements to consider in determining whether a VA medical examination must be provided). Here, as the Veteran’s service records confirm that he participated in parachute jumps and that he sought treatment for bilateral lower extremity pain, and as the Veteran has related the physical trauma associated with these jumps to his current complaints of the bilateral lower extremities, the Board finds that the low threshold of McLendon has been met and the Veteran should be provided with a VA examination to ascertain the likely nature and etiology of any knee/ankle complaints. With respect to the Veteran’s right eye claim, he testified that he injured his right eye in service while chiseling a wheel bearing off of a truck and that his vision deteriorated in that eye since the injury. The Veteran’s December 1978 Report of Medical Examination at enlistment into service indicated that his right eye distant vision was 20/40. A review of the Veteran’s service treatment records confirms that he sought treatment for tearing in the right eye in November 1984 after the chisel with which he was working splintered and caused a piece of metal to hit the eye. He was diagnosed as having a corneal abrasion and prescribed an eye patch. Later, in February 1987, the Veteran sought treatment for a watery eye, at which time he was diagnosed as having conjunctivitis. The Veteran was provided with a VA Eye Conditions examination in January 2014, at which time he was diagnosed as having a right eye corneal abrasion in November 1984 and right eye refractive amblyopia in January 2014. The VA examiner opined that the Veteran’s “vision problem” of reduced acuity right eye was not at least as likely as not caused by nor related to his in-service eye injury. In support of this conclusion, the VA examiner explained that, “Unexplained minor decrease in acuity OD, existed on enlistment. No evidence of ocular injury or disease to account for decreased vision OD. No signs of sequelae of the right eye injury in service on Nov 29,1984.” However, the Board finds that the January 2014 VA opinion is inadequate. Congenital or developmental defects and refractive error of the eye are not diseases or injuries within the meaning of applicable legislation. 38 C.F.R. § 3.303 (c). The determinative question is whether amblyopia was noted on entry into service, existed prior to service, or was incurred or aggravated in service. Although the VA examiner noted that the Veteran exhibited an “unexplained minor decrease” in right eye acuity at the time of his enlistment, the examiner did not provide an opinion as to the onset and etiology of his currently-diagnosed amblyopia. Furthermore, the VA examiner did not mention the complaints of watery eye in February 1987, which was diagnosed as conjunctivitis, and whether those symptoms were residual of the prior November 1984 corneal abrasion or represented a worsening of a preexisting eye disability. As such, on remand, an adequate VA medical opinion must be obtained. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (“Once VA undertakes the effort to provide an examination, it must provide an adequate one or, at a minimum, notify the veteran why one will not or cannot be provided.”). With respect to the Veteran’s hemorrhoids claim, he testified that he had been treated for hemorrhoids throughout his military career and into the present. A review of the Veteran’s service treatment records confirms that he was diagnosed as having external hemorrhoids in October 1981. Thereafter, in July 1982, the Veteran sought treatment for pain and bleeding upon defecation; at that time, there were no external hemorrhoids noted, but the Veteran was diagnosed as having an irritated anal area. The Veteran was provided with a VA Rectum and Anus Conditions examination in January 2014, at which time the Veteran reported itching and burning in anal area, as well as blood upon wiping with all bowel movements. However, the VA examiner did not provide an etiological opinion because no external hemorrhoids were perceived upon examination. The VA examiner explained that, “Exam for internal hemorrhoids could not be done; no equipment available. External hemorrhoids were not found. Redundant tissue found encircling anus is not the same as external hemorrhoids.” Significantly, the Board notes that an examination for internal hemorrhoids was not conducted at that time because the necessary equipment was unavailable. On remand, the Veteran should be scheduled for a new VA examination so that a proper examination for internal hemorrhoids can be conducted. See Barr, supra. With respect to the Veteran’s pseudofolliculitis barbae claim, he testified that he was first treated for this condition in service and that it continued into the present. A review of the Veteran’ service treatment records reveals that he was treated for this condition on several occasions in 1982 and 1983, and that he was placed on a physical profile allowing for shaving accomodation. The Veteran was provided with a VA Skin Diseases examination in January 2014, at which time the examiner indicated that he had a history of pseudofolliculitis barbae that had resolved without residuals. The VA examiner did not provide an etiological opinion because he had determined that there was no current condition found. The examiner explained that the Veteran had not been treated for this condition since military discharge; that the Veteran was treated by a private dermatologist for alopecia areata of the scalp and bearded area in 2003 and 2004, at which time pseudofolliculitis barbae was not noted, and that the Veteran did not exhibit any pathologic condition of the bearded area upon current examination. However, at his February 2019 Board hearing, the Veteran contended that he still suffered from pseudofolliculitis barbae and that he was currently prescribed medication by VA to treat it. A review of the Veteran’s VA treatment records confirms that he was prescribed clindamycin phosphate 1% lotion as recently as February 2020, with instructions to apply sparingly to the affected area every day. Given the Veteran’s competent testimony that he is still afflicted by pseudofolliculitis barbae and VA treatment records dated as recently as February 2020 showing prescription of clindamycin phosphate 1% lotion, the Board finds that he should be provided with another VA examination to determine the likely nature and etiology of any current pseudofolliculitis barbae. With respect to the Veteran’s TBI and headache claims, he testified that his headaches resulted from his numerous hard landings on parachute jumps as well as a motor vehicle accident in service. He additionally testified that he began experiencing difficulty concentrating and memory loss during service, which he attributed to an in-service head injury, although he did not seek treatment for these symptoms until after service. A review of the Veteran’ service treatment records reveals reoccurring complaints of headaches in October 1979, July 1980, and September 1982, which were often diagnosed as tension headaches. Additionally, in February 1985, he was involved in a motor vehicle accident, after which time he sought treatment for severe head pain and multiple small forehead lacerations caused by broken glass. The Board emphasizes that headaches were not noted at the time of the Veteran’s enlistment into active duty in June 1979; as such, he is presumed to have been in sound condition as to these disorders upon entry into service. The Veteran was provided with a VA Headaches examination in November 2013, at which time he was diagnosed as having migraine headaches, including migraine variants. However, the VA examiner explained that: Veteran states that he has had difficulty with moderate to severe headaches all his life, definitely before he entered into the service. At other times he stated that he headaches which began after several hard landings as a parachutist. There is also a history of a head injury from a motor vehicle accident when he was intoxicated. There is no clear history which can document any relationship between his military service in the headaches. Since the veteran stated to this examiner that his headaches began before entry into the service, although he does have headache pain, and appears less likely than not that it is related to or exacerbated by his military service. They are frontotemporal, associated with some nausea light sound and motion sensitivity and can last anywhere from a half hour to several hours. He states it can be frustrating one to 3 times per week for a few hours. Here, the Board finds that the November 2013 VA Headaches examination is inadequate. The VA examiner appeared to find that the Veteran’s headaches were less likely than not related to or exacerbated by his military service based on the Veteran’s own inconsistent statements that the headaches preexisted service. However, as mentioned above, headaches were not mentioned upon the Veteran’s entry into active duty service. Therefore, the presumption of soundness still applies, and there must be clear and unmistakable evidence to demonstrate that a headache disorder existed before enrollment in service and that it was not aggravated by such service. 38 U.S.C. § 1111. The examiner did not address whether this onerous evidentiary standard was met by the Veteran’s subsequent inconsistent statements as to the onset of headaches. Therefore, a remand is necessary to address whether the Veteran’s headache condition preexisted service and, if so, whether they were aggravated during service. If not, then a direct service-connection opinion is necessary. With respect to the Veteran’s acquired psychiatric disorder claim, he asserted that he suffers from PTSD and substance abuse as a result of various in-service stressors. In a statement received in May 2019, the Veteran described several stressors which he attributed to his current psychiatric symptoms: (1) general stress associated with supervising 27 soldiers in his capacity as a motor maintenance supervisor while stationed with the 245th Air Traffic Control Squadron at Fort Bragg, North Carolina; (2) the fear of being in range of East German missiles while stationed in West Germany in 1981; (3) fear associated with flying into Granada in full combat gear but without ammunition on a patrol mission to recover dead bodies as part of the U.S. invasion of Grenada in 1983, at which time they received gunfire to their Lockheed C-130 Hercules transport aircraft upon landing; and (4) fear associated with flying over Libya following the U.S. bombing of Muammar Gaddafi’s compound as part of Operation El Dorado Canyon (although the Veteran attributed this event to 1984, Operation El Dorado Canyon occurred in 1986). At his Board hearing, the Veteran identified additional PTSD stressors such as being overworked by his supervisor in Germany and collecting dead bodies in body bags in Grenada. A review of the Veteran’s service records confirms that he was stationed with the 324th Signal Company in Germany from August 1981 to June 1983. However, his personnel records do not reflect any additional overseas service (to include any service in Grenada and/or Libya). His personnel records also confirm that he served in the capacity of a wheeled vehicle mechanic supervisor while stationed with the 245th Air Traffic Control Squadron at Fort Bragg, North Carolina, from 1985 to 1986. The Veteran was provided with a VA PTSD examination in November 2013, at which time he was diagnosed as having cocaine dependence in recent remission. Significantly, the VA examiner only analyzed one alleged stressor: the Veteran’s fear of being deployed to Libya and potentially put in harm's way. The VA examiner indicated that this single stressor was not adequate to support a PTSD diagnosis, nor was it related to the Veteran's fear of hostile military or terrorist activity. However, as two of the Veteran’s other claimed stressors (general stress associated with supervising soldiers in his capacity as a motor maintenance supervisor while stationed with the 245th Air Traffic Control Squadron at Fort Bragg, North Carolina; and the fear of being in range of East German missiles while stationed in West Germany in 1981) have since been corroborated by the record, the Board finds that an addendum opinion is necessary to determine whether these stressors could potentially support a PTSD diagnosis. The matters are REMANDED for the following action: 1. Associate legible copies of the VA Form 21-4142 and VA Form 21-4142a submitted by the Veteran via facsimile on April 23, 2020, with the claims file. If legible copies do not exist, then request that the Veteran resubmit the VA Form 21-4142 and VA Form 21-4142a. All efforts to obtain these records should be documented and any negative response should be recorded in the claims file. Two requests should be made for the authorized records from each identified source, unless it is clear, after the first request, that a second request would be futile. 38 C.F.R.§3.159(c)(2). Notify the Veteran if the authorized records cannot be located. 2. Schedule the Veteran for a VA examination to ascertain the probable nature and etiology of his claimed disabilities of the bilateral knees and ankles. The claims file must be made available to, and reviewed by, the examiner. Any indicated studies should be performed. Based on the examination results and the review of the record, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any disability of the bilateral knees and/or ankles began in service, was caused by service, or is otherwise etiologically related to active service. In providing these opinions, the examiner is asked to specifically address the Veteran’s testimony that his knee and ankle symptoms were due to the trauma associated with the 126 parachute jumps he made while in service; the Veteran’s receipt of the Parachute Badge and Canadian Parachute Badge, as well as his completion of 3 weeks of Basic Airborne training in 1979; service treatment records demonstrating ankle sprains in March 1981 and May 1983, as well as treatment for pain in the bilateral lower extremities which was diagnosed as shin splints in February 1987; and VA treatment records showing diagnosis of knee arthralgia. If there is any clinical or medical basis for corroborating or discounting the credibility of the history provided by the Veteran, then the examiner must so state, with a complete explanation in support of such a finding. The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of conclusion as it is to find against it. The examiner must discuss the underlying rationale for all opinions expressed. If any opinion cannot be rendered without resorting to speculation, then the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge, or by a deficiency in the record or the examiner. 3. Obtain an addendum opinion from the examiner who provided the January 2014 VA Eye Conditions examination, or if unavailable, another suitably qualified VA medical professional, to determine likely onset and etiology of his diagnosed right eye amblyopia. The examiner must review the claims file. If, after review of the claims file, the examiner determines that another VA examination is necessary, then such must be scheduled and the Veteran must be notified. Since decreased visual acuity in the right eye was noted on the Veteran’s December 1978 Report of Medical Examination at enlistment, prior to his period of active duty service, he is not presumed to have been in sound condition as to this disorder upon entry into service. The examiner should state the following: a. Whether amblyopia clearly and unmistakably (evidence that cannot be misinterpreted and misunderstood, undebatable) preexisted the Veteran’s service. b. If the examiner finds amblyopia did clearly and unmistakably preexist service, then the examiner must opine whether it was clearly and unmistakably not aggravated by service. c. If the examiner finds that amblyopia either did not clearly and unmistakably preexist service, or was not clearly and unmistakably aggravated by service, then the examiner must opine whether it is at least as likely as not (50 percent probability or greater) related to an in-service injury, event, or disease, including right eye corneal abrasion, conjunctivitis, and/or head trauma (related to the February 1985 motor vehicle accident). In providing these opinions, the VA examiner should specifically acknowledge and discuss the December 1978 Report of Medical Examination at enlistment showing 20/40 vision in the right eye; the November 1984 right eye injury diagnosed as corneal abrasion; the February 1985 motor vehicle accident, at which time the Veteran was treated for severe head pain and multiple small forehead lacerations caused by broken glass; and the February 1987 diagnosis of conjunctivitis. If there is any clinical or medical basis for corroborating or discounting the credibility of the history provided by the Veteran, then the examiner must so state, with a complete explanation in support of such a finding. The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of conclusion as it is to find against it. The examiner must discuss the underlying rationale for all opinions expressed. If any opinion cannot be rendered without resorting to speculation, then the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge, or by a deficiency in the record or the examiner. 4. Schedule the Veteran for a VA examination to address the probable nature and etiology of his claimed hemorrhoids. The claims file must be made available to, and reviewed by, the examiner. If external hemorrhoids are not perceived upon examination, then arrangements must be made for the Veteran to be examined for internal hemorrhoids. Based on the examination results and review of the record, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any hemorrhoid disability began in service, was caused by service, or is otherwise etiologically related to active service. In providing these opinions, the examiner is asked to specifically address the October 1981 diagnosis of external hemorrhoids as well as the July 1982 treatment for pain and bleeding upon defecation (at which time the Veteran was diagnosed as having an irritated anal area). The examiner is also asked to acknowledge and consider the Veteran’s competent reports of hemorrhoid symptomatology since service. If there is any clinical or medical basis for corroborating or discounting the credibility of the history provided by the Veteran, then the examiner must so state, with a complete explanation in support of such a finding. The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of conclusion as it is to find against it. The examiner must discuss the underlying rationale for all opinions expressed. If any opinion cannot be rendered without resorting to speculation, then the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge, or by a deficiency in the record or the examiner. 5. Schedule the Veteran for a VA examination to ascertain the probable nature and etiology of his claimed pseudofolliculitis barbae. The claims file must be made available to, and reviewed by, the examiner. Any indicated studies should be performed. If the disability is subject to flare-ups, then the medical examination should, if possible, evaluate the condition during a flare-up. Compare Ardison v. Brown, 6 Vet. App. 405, 408 (1994) (examination was inadequate when administered during the inactive stage of the claimant’s condition), with Voerth v. West, 13 Vet. App. 117, 123 (1999) (the Board is not required to provide an examination during a flare-up where flare-ups lasted “only for a few days out of a year”). Based on the examination results and the review of the record, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any current pseudofolliculitis barbae was caused by service, had its initial onset in service, or is otherwise etiologically related to active service. In providing these opinions, the examiner is asked to specifically address the Veteran’s competent testimony that his pseudofolliculitis barbae had its initial onset in service and continued into the present, as well as the VA treatment records dated as recently as February 2020 showing that the Veteran was prescribed clindamycin phosphate 1% lotion with instructions to apply sparingly to the affected area every day. If there is any clinical or medical basis for corroborating or discounting the credibility of the history provided by the Veteran, then the examiner must so state, with a complete explanation in support of such a finding. The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of conclusion as it is to find against it. The examiner must discuss the underlying rationale for all opinions expressed. If any opinion cannot be rendered without resorting to speculation, then the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge, or by a deficiency in the record or the examiner. 6. Obtain an addendum opinion from the examiner who provided the November 2013 VA Headaches examination, or if unavailable, another suitably qualified VA medical professional, to determine likely onset and etiology of his diagnosed headaches. If, after review of the claims file, the examiner determines that another VA examination is necessary, then such must be scheduled and the Veteran must be notified. Since headaches were not noted on the Veteran’s December 1978 Report of Medical Examination at enlistment, he is presumed to have been in sound condition as to this disorder upon entry into service. The examiner should state the following: a. Whether a headache disorder clearly and unmistakably (evidence that cannot be misinterpreted and misunderstood, undebatable) preexisted the Veteran’s service. b. If the examiner finds it did clearly and unmistakably preexist service, then the examiner must opine whether it was clearly and unmistakably not aggravated by service. c. If the examiner finds that it either did not clearly and unmistakably preexist service, or was not clearly and unmistakably aggravated by service, then the examiner must opine whether it is at least as likely as not (50 percent probability or greater) related to an in-service injury, event, or disease, including head trauma related to the February 1985 motor vehicle accident. In providing these opinions, the VA examiner should specifically acknowledge and discuss the reoccurring complaints of headaches in October 1979, July 1980, and September 1982 (which were often diagnosed as tension headaches), as well as the February 1985 motor vehicle accident (at which time the Veteran sought treatment for severe head pain and multiple small forehead lacerations caused by broken glass). If there is any clinical or medical basis for corroborating or discounting the credibility of the history provided by the Veteran, then the examiner must so state, with a complete explanation in support of such a finding. The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of conclusion as it is to find against it. The examiner must discuss the underlying rationale for all opinions expressed. If any opinion cannot be rendered without resorting to speculation, then the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge, or by a deficiency in the record or the examiner. 7. Obtain an addendum opinion from the examiner who provided the November 2013 VA PTSD examination, or if unavailable, another suitably qualified VA medical professional, to determine likely nature and etiology of any diagnosed psychiatric disorder. If, after review of the claims file, the examiner determines that another VA examination is necessary, then such must be scheduled and the Veteran must be notified. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran’s service treatment records, post-service medical records, and assertions. a. Identify all current psychiatric disorders. If any previously diagnosed psychiatric disorders are not found on examination, then the examiner should address whether they were previously misdiagnosed or have since resolved. b. For each diagnosis identified other than PTSD, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the disorder manifested in or is otherwise causally or etiologically related to the Veteran’s military service. c. Regarding PTSD, the examiner is asked to consider two additional stressors alleged by the Veteran: general stress associated with supervising 27 soldiers in his capacity as a motor maintenance supervisor while stationed with the 245th Air Traffic Control Squadron at Fort Bragg, North Carolina; and the fear of being in range of East German missiles while stationed in West Germany in 1981. With respect to each of these stressors, the VA examiner should determine whether the diagnostic criteria to support the diagnosis of PTSD have been satisfied. If the PTSD diagnosis is deemed appropriate, then the examiner should then comment upon the link between the current symptomatology and any verified in-service stressor. The examiner should note that the Veteran is competent to attest to factual matters of which he has first-hand knowledge. If there is a medical basis to support or doubt the history provided by the Veteran, then the examiner should state this with a fully reasoned explanation. The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of conclusion as it is to find against it. (Continued on the next page)   A clear rationale for all opinions must be provided and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 8. After undertaking any other development (to include additional VA examinations and opinions) deemed appropriate as a result of the above-requested development, readjudicate the issues on appeal. If any benefit sought is not granted, then the Veteran and his agent should be provided with a Supplemental   Statement of the Case and afforded an opportunity to   respond. Then return the case to the Board for further review if otherwise in order. Tiffany Dawson Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Anthony M. Flamini 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.