Citation Nr: 21000741 Decision Date: 01/06/21 Archive Date: 01/06/21 DOCKET NO. 17-23 451 DATE: January 6, 2021 ORDER Service connection for an acquired psychiatric disorder, to include post-traumatic stress disorder (PTSD), major depressive disorder (MDD) and alcohol use disorder, is granted. REMANDED Service connection for bilateral foot fungus is remanded. Service connection for skin blisters of scrotum, bilateral legs and bilateral ankles is remanded. FINDINGS OF FACT Resolving reasonable doubt in the Veteran’s favor, it is at least as likely as not that his acquired psychiatric disorder is related to active duty service. CONCLUSIONS OF LAW The criteria for entitlement to service connection for an acquired psychiatric disorder, to include PTSD, depression and alcohol use disorder, have been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.304. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1990 to September 1993. In December 2019, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record. This matter returns to the Board of Veterans’ Appeals (Board), following a March 2020 remand, which had requested additional development and new VA medical examinations. The Board acknowledges that the Veteran filed a claim for entitlement to service connection for a psychiatric disorder that included PTSD. However, a service connection claim which describes only one particular psychiatric disorder should not necessarily be limited to that disorder, and VA should consider the claim as one for any psychiatric disability that may reasonably be encompassed by evidence of record. Clemons v. Shinseki, 23 Vet. App. 1, 5-6 (2009). Therefore, the Board has re-characterized the psychiatric issues on appeal as PTSD, MDD and alcohol use disorder. Service Connection 1. Entitlement to service connection for an acquired psychiatric disorder to include PTSD, MDD and alcohol use disorder. The Veteran asserts that his psychiatric disorders are related to his active duty naval service. The law provides that service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.303, 3.304. Service connection may be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Generally, establishing service connection requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999). Based on the evidence of record, and resolving all doubt in favor of the Veteran, the Board determines that service connection is warranted for the Veteran’s psychiatric disorder. Initially, the Board notes that the post-service medical evidence shows that the Veteran has been diagnosed with at least three psychiatric disorders. Specifically, he received diagnoses of major depressive disorder and alcohol use disorder in August 2015 and was diagnosed with PTSD in May 2020. Next, the Board determines that the evidence is at least in equipoise as to whether the Veteran’s acquired psychiatric disorders began in service or shortly thereafter. In his August 1993 separation examination, he listed his psychiatric condition as “normal”. However, several letters from his family, spouse, fellow service-members and a childhood friend describe worsening psychiatric symptoms that began in or shortly after service. These symptoms include excess alcohol use, social isolation, difficulty sleeping and suicidal ideations. Moreover, the August 2015 VA examiner diagnosed him with MDD and alcohol use disorder, stating that his symptoms began in service. The examiner wrote that he “appears to have had his disorders for a long time, during his adult life”. The examiner clarified that these disorders were at least as likely as not related to service, causing him tremendous stress and feelings of inadequacy while in the Navy. In his December 2019 Hearing, the Veteran testified that he has had psychiatric “trouble” from the time of his separation until he sought counseling through the VA. The Board acknowledges the negative medical evidence includes a May 2020 VA examination for PTSD, which did not find a nexus between his PTSD and service, as well as August and November 2015 VA examinations which did not diagnose the Veteran with PTSD. The November 2015 and May 2020 VA examinations are silent with regards to his diagnosed MDD and alcohol use disorder. However, as noted above, the medical evidence including the August 2015 examiner’s opinion, reflect that he began experiencing psychiatric symptoms in-service, which have been continuous since separation. Thus, the Board finds the evidence is in relative equipoise to support service connection given that the onset of his symptoms occurred during service and the continuity of his symptoms thereafter. By virtue of the foregoing, the Board concludes that the evidence is in relative equipoise and that the Veteran’s claim seeking service connection for an acquired psychiatric disorder should be granted. REASONS FOR REMAND 1. Entitlement to service connection for bilateral foot fungus is remanded. 2. Entitlement to service connection for a skin condition, to include skin blisters on the scrotum, bilateral legs, and bilateral ankles is remanded. The Veteran has claimed that his bilateral foot fungus and skin condition are related to service. Specifically, that their respective onsets occurred in Boot Camp and while on deployment to the Persian Gulf aboard the USS INDEPENDENCE (CV-62). This matter was remanded by a Board decision in March 2020 for an examination to evaluate the nature and etiology of his skin condition and bilateral foot fungus. The remand decision specifically directed the examiner to provide a complete and fully explanatory rationale for all opinions required. The Veteran was afforded an examination for both disorders in September 2020. With respect to the Veteran’s bilateral foot fungus, the examiner diagnosed him with chronic onychomycosis – fungal infection of the toenails. While this diagnosis was provided, the examiner also indicated there was no chronic diagnosis made for bilateral foot fungus. The rationale provided that bilateral foot fungus is “a chronic disease which represents less than 5% of [sic] this veterans total body composition.” The examiner later wrote that his bilateral foot fungus does not impact his daily life and is controlled with use of daily topical anti-fungal medication. The Board recognizes that the examiner’s opinion is internally inconsistent regarding whether there is a current diagnosis of a bilateral fungal infection of the lower extremities of either the feet or toenails. Additionally, the examiner notes that the Veteran’s medical records are silent for the claim of bilateral foot fungus while failing to address his competent and credible testimony at the December 2019 Board hearing, as well as a buddy statement reflecting bilateral foot fungus in service. Due to the foregoing, the examination is inadequate in its current state. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008). Moreover, the Board must ensure that all remand directives are complied with substantially. See Stegall v. West, 11 Vet. App. 268 (1998). With respect to the Veteran’s claim seeking service connection for a skin condition, to include skin blisters on the scrotum, bilateral legs, and bilateral ankles, the Board finds the September 2020 examination to be inadequate. The examiner stated that his scrotal blisters were acute in nature, with “no documentation, in medical records, reflecting treatment of blisters on scrotum” since service. The opinion fails to note that the Veteran sought treatment for his skin condition through the VA in February and April 2015 as referenced in the prior Board remand. The opinion also fails to address his testimony before the Board and his buddy’s statement regarding visible blisters on his ankles and legs during service. The Board notes that in October 2020, the Veteran submitted a statement challenging the adequacy of the September 2020 examination. He wrote that the September 2020 examiner did not inspect his scrotum area saying there was no need to expose himself. The Veteran stated that the examiner refused to examine pictures of his scrotum, and stated that all she needed was evidence of prescribed medication for his skin condition. He later sent an e-mail with pictures of both his scrotal blisters as well as the medication, which is of record. Based on the examiner’s opinion as well as the Veteran’s statement challenging its adequacy, a remand regarding his skin condition claim for an addendum opinion is necessary. Stegall, 11 Vet. App. 268. The matters are REMANDED for the following action: Schedule the Veteran for a VA examination by an appropriate clinician to determine the nature, extent, onset, and etiology of his skin condition, to include skin blisters of the scrotum, bilateral legs, bilateral ankles and bilateral foot fungus. The examiner should conduct an examination of the Veteran’s scrotum area to determine whether a current diagnosis is warranted. The claims file should be provided to the examiner(s), including this Order and the Hearing transcript, for review. All indicated studies deemed necessary by the examiner(s) should be performed, and all findings of those tests should be reported in detail. The examiner should provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that any currently diagnosed skin condition, to include skin blisters on the scrotum, bilateral legs, and bilateral ankles, is etiologically related to the Veteran’s period of active duty service. The examiner should also provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that any currently diagnosed bilateral foot fungus is etiologically related to the Veteran’s period of active duty service. If the examiner cannot provide any of the requested opinions without resorting to speculation, he or she should provide an explanation stating why this is so. In so doing, the examiner should explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). 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. B.T. KNOPE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. McDonald