Citation Nr: 21067494 Decision Date: 11/04/21 Archive Date: 11/04/21 DOCKET NO. 07-33 365 DATE: November 4, 2021 REMANDED Entitlement to service connection for arthritis is remanded. Entitlement to service connection for gout is remanded. Entitlement to service connection for a left shoulder disability is remanded. Entitlement to service connection for a left foot disability, to include as secondary to a service-connected disability, is remanded. Entitlement to service connection for headaches is remanded. Entitlement to service connection for a psychiatric disability, claimed as posttraumatic stress disorder (PTSD), is remanded. Entitlement to an initial rating in excess of 20 percent for diabetes mellitus is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1970 to September 1971. He died in February 2012. The Appellant is the Veteran's surviving who has been substituted as claimant for her late husband's claims that remained pending at the time of his death for purposes of seeing the claims to completion. 1. Entitlement to service connection for arthritis is remanded. 2. Entitlement to service connection for gout is remanded. 3. Entitlement to service connection for a left shoulder disorder is remanded. 4. Entitlement to service connection for a left foot disability, to include as secondary to a service-connected disability, is remanded. 5. Entitlement to service connection for headaches is remanded. 6. Entitlement to service connection for a psychiatric disability, claimed as PTSD, is remanded. 7. Entitlement to an initial rating in excess of 20 percent for diabetes mellitus is remanded. The Veteran's VA treatment records contain notations indicating that a VA employee scanned medical records into a VA hospital's imaging system, but do not contain any copies of the scanned records. Any treatment records scanned into a VA hospital's imaging system are within VA's constructive possession and are considered potentially relevant to the issues on appeal. Remand is required to allow VA to obtain those records. Additionally, the Veteran received treatment for a mental disorder at a Vet Center in Lexington, Kentucky. In an October 2007 summary of treatment, a Vet Center examiner indicated that the center provided the Veteran with individual psychiatric counseling on 20 occasions between February 2006 and October 2007. The record does not contain any Vet Center records other than that summary. Remand is necessary to attempt to obtain any outstanding Vet Center records. The Veteran claimed to have been exposed to enemy activity during service in Vietnam. Before passing, the Veteran did not provide VA with sufficient details of the claimed PTSD stressor incidents to allow VA to corroborate the stressors. However, VA regulations authorize service connection for PTSD to be allowed if a VA psychiatrist or psychologist determines that the Veteran had diagnosed PTSD which was related to the fear of hostile enemy or terrorist activity during service. Remand is necessary to obtain a VA medical opinion regarding the etiology of any mental disorder. The matters are REMANDED for the following action: 1. Obtain all outstanding VA treatment records. Specifically, obtain the most recent VA treatment records not included in the record of evidence and the records noted as having been scanned into the Vista imaging system by VA Medical Center personnel, as noted in the VA treatment records in evidence, dated February 11, 2011; May 4, 2010; June 25, 2008; and March 21, 2006. 2. Obtain the Veteran's records from the Vet Center in Lexington, Kentucky. Document all requests for information as well as all responses in the claims file. 3. Provide access to the claims file to a VA psychiatrist or psychologist to obtain a medical opinion to determine the nature and etiology of any psychiatric disability, to include PTSD. The examiner must review the claims file, to include the service medical records; the post-service medical records, to include those indicating treatment for a psychiatric disability; and the lay evidence of record, to include the statements from both the Veteran and the appellant, his spouse. A complete rationale should be provided for all opinions and conclusions. The examiner is asked to offer the following opinions: (a.) Diagnose all psychiatric disabilities experienced by the Veteran between January 2006 and the date of death, February 2, 2012. (b.) If a diagnosis of PTSD is warranted under the diagnostic criteria, opine whether it is at least as likely as not (50 percent or greater probability) that PTSD was the result the fear of hostile military or terrorist activity during service in Vietnam. (c.) If the Veteran had a diagnosed psychiatric disability other than PTSD, opine whether it is at least as likely as not (50 percent or greater probability) that each psychiatric disability was related to service or any event, injury, or disease during service. Harvey P. Roberts Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T.M. Gillett 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.