Citation Nr: 21010425 Decision Date: 02/24/21 Archive Date: 02/24/21 DOCKET NO. 19-06 150A DATE: February 24, 2021 ORDER Service connection for residuals of stroke is denied. Service connection for pneumothorax is denied. Service connection for lumbar scoliosis with degenerative disc disease/degenerative joint disease to include as secondary to the shrapnel wounds of the bilateral lower extremities is denied. Service connection for radiculopathy, bilateral lower extremities to include as secondary to the shrapnel wounds of the bilateral lower extremities and due to herbicide exposure is denied. The application to reopen the claim of entitlement to service connection for a dental condition due to trauma is granted. Service connection for dental condition due to trauma is denied. REMANDED Entitlement to a rating in excess of 50 percent for somatic symptom disorder is remanded. Service connection for atrial fibrillation (claimed as heart irregular) to include as secondary to the somatic symptom disorder is remanded. FINDINGS OF FACT 1. Neither a stroke nor stroke residuals was not manifest in service or within one year of separation. Stroke residuals are unrelated to service and are unrelated (caused or aggravated) to service-connected disease or injury. 2. There are no residuals of the small pneumothorax, a transient condition, that occurred in service. Current shortness of breath manifested years following service and is unrelated to service. 3. A low back disability, to include lumbar spine spondylosis with degenerative disc disease, did not manifest in service nor did it manifest within one year of separation, is not otherwise related to service and is unrelated (caused or aggravated) to service-connected disease or injury. 4. Radiculopathy, bilateral lower extremities did not manifest in service nor did it manifest within one year of separation is not otherwise related to service to include herbicide exposure therein, and is unrelated (caused or aggravated) to service-connected disease or injury. 5. In an unappealed April 1970 rating decision, the RO denied service connection for dental condition because there was no evidence of a traumatic dental injury. 6. Evidence received since the April 1970 rating decision is not cumulative and redundant of evidence previously of record and does relate to an unestablished fact necessary to substantiate the claim of service connection for dental condition due to trauma. 7. A dental disorder was not manifested by the loss of substance of the maxilla or mandible due to trauma or osteomyelitis during the Veteran’s period of active service. CONCLUSIONS OF LAW 1. The criteria for service connection for residuals of stroke are not met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 2. The criteria for service connection for pneumothorax are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for service connection for a low back disability, to include lumbar spine spondylosis with degenerative disc disease, are not met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a)-(b), (d), 3.307, 3.309(a), 3.310. 4. The criteria for service connection for radiculopathy, bilateral lower extremities, are not met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a)-(b), (d), 3.307, 3.309(a), 3.310. 5. New and material evidence has been received to reopen the claim of service connection for a dental condition due to trauma, the claim is reopened. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 6. The criteria for service connection for dental disorder for VA compensation purposes have not been met. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.303, 3.304, 3.381, 4.150. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from November 1967 to September 1969, including service in Vietnam. His awards and decorations include Purple Heart, Combat Action Ribbon, Vietnam Campaign Medal, Vietnam Service Medal with one star and the National Defense Service Medal. We note that a newspaper article in the claims folder from 1970 reflects that he saved the lives of two comrades in combat. He appeals May 2013 and August 2014 rating decisions. He testified at a Board hearing before the undersigned Veterans Law Judge (VLJ) in December 2020. The VLJ clarified the issues on appeal to specifically be only the seven listed above; clarified the concept of service connection and increased ratings; identified potential evidentiary defects; clarified the type of evidence that would support the Veteran’s claims and inquired as to the existence of potential outstanding records. The undersigned was informed that there was no additional written evidence to be submitted. The actions of the VLJ comply with 38 C.F.R. § 3.103. Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service or for aggravation of a preexisting injury suffered or disease contracted in line of duty. 38 U.S.C. § 1110 (wartime), 1131 (peacetime). Service connection is also warranted for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (a). In general, to establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service - the so-called “nexus” requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009). Service connection may be granted for any disease initially diagnosed after service when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). For veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic diseases such as arthritis and organic diseases of the nervous system (including degenerative disc disease) will be presumed related to service if they were noted as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if continuity of the same symptomatology has existed since service, with no intervening cause. 38 U.S.C. §§ 1101, 1112, 1113, 1137; Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2012); Fountain v. McDonald, 27 Vet. App. 258 (2015); 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a). Service connection is also warranted for disability which is proximately due to, aggravated by or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (a). Such secondary service connection is warranted for any increase in severity of a nonservice-connected disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310 (b). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 C.F.R. § 3.102. The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). 1. Service connection for residuals of stroke is denied. First, the Veteran has not been afforded VA examination in connection with this claim and none was required. McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006); see 38 C.F.R. § 3.159 (c)(4). The evidence collectively fails to present an indication that the current disability, stroke residuals, may be associated with the Veteran’s service or with another service-connected disability. The service treatment records (STRs) do not show the occurrence of stroke, the stroke occurred in 2014. Furthermore, post-service medical records do not indicate the stroke may be associated with the Veteran’s service or with another service-connected disability, and there is no other lay evidence supporting a possible in-service incurrence or nexus. In sum, the entirety of the evidence in support of an in-service event and nexus, or connection to service-connected disability, consists of the Veteran’s lay statements dating from 2014 onward. Such lay statements are insufficient to trigger VA’s duty to assist by providing a medical examination. 38 C.F.R. § 3.159 (c)(4); McLendon, 20 Vet. App. at 81; see Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010). Second, for the reasons that follow, the preponderance of the evidence is against the claim. The question for the Board is whether the current stroke residuals manifested in service or whether the condition is otherwise related to service or related to service-connected disability. The Veteran urges in his February 2014 claim that the stroke he suffered that month was precipitated by recent ablation and is somehow due to service-connected disability. The VA treatment record reflects that he is status post accident (CVA) from February 2014. His recorded medical history reflects pulmonary vein ablation in 2014. No examiners or medical care providers have related the stroke to a service-connected disease or injury; there are only the Veteran’s recorded reports that his stroke occurred fairly close in time following ablation. Clearly it is not contended or suggested that the stroke occurred in service or for decades following service. Thus, we conclude that the current stroke residuals were not incurred in or otherwise related to service or within one year of separation. The weight of the competent evidence is against finding that the current condition is related to service. 38 U.S.C. § 1110; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303 (a), (d). Here, he did not have characteristic manifestations sufficient to identify this disease process during service or within one year of separation. Instead, it is asserted that the stroke was due to heart disease. See, e.g., Veteran’s testimony that he became stressed and began to have heart problems in the wake of the 2005 Hurricane Katrina that ultimately led to a stroke in 2014. However, there is no credible evidence that current disability is due to or aggravated by service-connected disease or injury. His assertions are not supported by any medical opinion. There is no suggestion in the record that there is a connection between his stroke and a service-connected disease or injury. To the extent that the heart disorder claim is being remanded, we note that there is no suggestion in the medical record that the stroke is related to a current heart disorder. This issue of nexus is medically complex, as it requires specialized medical education/knowledge of the interaction between multiple organ systems in the body/the ability to interpret complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). There are no Jandreau-type exceptions. Ultimately, the Board is not presented with competent evidence that the Veteran has stroke residuals related to a service-connected disability. Consequently, the Board gives no probative weight to the lay testimony of the Veteran as to nexus. The preponderance of the evidence weighs against the claim, and it is denied. 2. Service connection for pneumothorax is denied. The issue for the Board is whether there are current residuals of a pneumothorax that occurred in 1969 in service. For the reasons that follow, the preponderance of the evidence is against so finding. STRs reflect that in 1969 the Veteran was noted to have a small pneumothorax. The Veteran was injured in 1969 to include multiple shrapnel injuries to include the chest area. Service connection and a 10 percent rating are in effect for chest scars with retained foreign bodies. The Veteran testified that, “I have a metal in my lung. The metal is still there and I have a hard time breathing sometimes.” He stated he was not receiving any treatment for the pneumothorax. Significantly, the Veteran underwent VA examination for the respiratory conditions in March 2014 by an examining physician who reviewed the claims folder. Diagnoses included pneumothorax diagnosed in 1969. The examiner opined that it is less likely than not that the Veteran’s current lung condition and breathing problems are related to the events for which he received the combat award. The comprehensive rationale was as follows: In the vet's STRs in VBMS, there is a Medical Board note dated 8/8/1969, which states that the vet was injured on 6/15/1969 with multiple shrapnel injuries, which included a left-sided pneumothorax. It states the pneumothorax was successfully treated with a “needle aspiration,” and the vet's post pneumothorax chest x-ray showed his lungs were "clear and fully expanded.” The chest x-ray in Vista imaging dated 2004, shows the lungs to be fully expanded also. The vet's current shortness of breath began at about the same time as his cardiac problems and intermittent atrial fibrillation. He smoked only for a few years and stopped in 1969 following his lung injury. He has not been diagnosed with COPD. Therefore, because his pneumothorax was a transient phenomenon, that was treated with a battle-field needle aspiration, and he needed no other chest procedure, and his post-pneumothorax chest x-ray was reported as “clear and [the lungs were] fully expanded,” and because he did smoke cigarettes for several years, and the shortness of breath began at about the same time as his cardiac problems began, it is less likely than not that the 1969 combat injury/pneumothorax is related to his current lung/shortness of breath. The 2014 VA opinion is also highly persuasive evidence against finding any nexus between any current lung/shortness of breath and service. The opinion is thorough, the examiner considered the entire record as stated. The preponderance of the evidence is against finding that a nexus exists between the Veteran’s any current lung/shortness of breath and the small pneumothorax in service. 38 U.S.C. § 1110; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303 (a), (d). Current symptoms have not been attributed by any competent evidence to service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. The Veteran’s contentions pale in comparison to the medically uncontroverted opinion of a trained VA medical professional on this matter of medical etiology. Also, as pointed out by the undersigned at the hearing, pain related to the metal in his chest has been addressed in the chest scars with retained foreign bodies rating. The preponderance of the evidence weighs against the claim, and it is denied. 3. Service connection for lumbar scoliosis with degenerative disc disease/degenerative joint disease to include as secondary to the shrapnel wounds of the bilateral lower extremities is denied. 4. Service connection for radiculopathy, bilateral lower extremities (claimed as pain in both legs) to include as secondary to the shrapnel wounds of the bilateral lower extremities and due to herbicide exposure is denied The Veteran urges that current low back disability began sometime after 2000. He reports it is related to service since he was hit with shrapnel in the back. He testified, “I related it to that. I’ve been hit with shrapnel all over the place. Both my legs. My heel. My Achilles tendon. Both arms and my face. And jaw. When I lost my eye due to shrapnel too.” He further argues that the radiculopathy is due to this back problem. A question for the Board is whether the Veteran has a current low back disorder that manifested in service or within any applicable presumptive period, or whether the condition is otherwise related to service or service-connected disability. There is current disability demonstrated in the March 2014 VA examination, to include lumbar spine spondylosis with degenerative disc disease and radiculopathy, with an approximate date of diagnosis in 2014. At the examination, the history was reported indicating March 1969 shrapnel wounds from a grenade lead to pneumothorax, right Achilles tear, soft tissue wounds and then he returned to field in 3 weeks. Another 1969 incident involved facial trauma and loss of left eye and severe injury to legs. Post service VA myelogram recent to the exam showed spinal stenosis, DJD and DDD. See 2014 VA back examination. The VA examiner stated that the Veteran’s back condition is less likely than not a result of the shrapnel wounds he received in service. The examiner stated that the veteran required little if any treatment for his low back for decades after service. While the Veteran’s current back disorder (arthritis or DJD and DDD as other organic disease of the nervous system) constitutes chronic disease under 38 U.S.C. § 1101(3); 38 C.F.R. § 3.309(a), such did not manifest in service or within a presumptive period, and continuity of symptomatology is not established. Rather, as observed by the VA examiner in 2014, the current low back disability was diagnosed in 2014. The 2014 examiner considered the Veteran’s assertions but provided adequate rationale to support a negative opinion. Also, the August 1969 medical Board review does not indicate any low back disorder or radiculopathy. The Board finds there was no chronic disease shown in service or for years following service. Here, we accept that there was injury during service and such injury would be consistent with the nature and circumstances of service. 38 U.S.C. § 1154(b). However, section 1154 only addresses what happened then. Here, there is no proof of a nexus to service. Rather, low back pathology was first identified long after separation from service. Ultimately, there is a gap of many years between service and the diagnosis or manifestation of a low back disorder, and the current disorder has been found by the 2014 VA examiner to be unrelated to service. 38 U.S.C. §§ 1101(3), 1112, 1113, 1137; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a). While the Veteran is competent to report having experienced certain symptoms, the record does not show chronic disease in service and his assertions, to the extent that he asserts continuity since service, are outweighed by the documented gap in the record and the trained examiner’s 2014 finding. The medical opinion is fully explained, considered the evidence of record and considered the Veteran’s contentions. The preponderance of the evidence is also against finding that a nexus exists between the Veteran’s current low back disability and service. 38 U.S.C. § 1110; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). Again, the current DJD and DDD of the low back began years after service and have not been related to service by any competent and credible evidence. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Moreover, there is no competent evidence that the current back problems are proximately due to or aggravated by the service-connected lower extremity scars to include right lower extremity scar with retained foreign body at the ankle. The Board gives considerable probative weight to the competent medical evidence, which shows that the current low back disorder first manifested years after service and is unrelated to service to include the in-service shrapnel wounds. The weight of the evidence is against concluding that any such disease was incurred in service. 38 C.F.R. § 3.303 (d). The weight of the evidence is also against concluding that the current back disorder is due to or aggravated by the shrapnel wound scars of the lower extremities, as there is no competent evidence in support of this argument. 38 C.F.R. § 3.310. The Board has considered the Veteran’s assertions. This issue here is medically complex, as it requires specialized medical education/knowledge of the interaction between multiple organ systems in the body/the ability to interpret complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). The Board gives more probative weight to the competent and credible medical evidence, which shows that the back disorder is not related to service. The lay contentions as to a relationship pale in comparison to the opinion of a trained medical professional. The claim is denied. As to bilateral lower extremity radiculopathy, we note that this has been diagnosed and attributed to the current low back disorder by the 2014 VA examiner. See 2014 examination diagnosis. The problem list in the VA treatment record reflects radiculopathy not before February 2013. The VA examiner’s assessment that the radiculopathy is due to the back is medically uncontroverted. Moreover, the record reflects that there is no finding of early onset peripheral neuropathy of the lower extremities which would warrant consideration of presumptive service connection regulations based on his presumed Agent Orange exposure. See, e.g., June 2015 Agent Orange peripheral neuropathy review performed by a VA physician. See 38 C.F.R. § 3.307 (e). Also, service connection for lower extremity peripheral neuropathy was previously denied in an unappealed rating decision. The preponderance of the evidence is thus against finding that the current bilateral lower extremity radiculopathy (1) was manifest in service or until decades following service, (2) is otherwise related to service. The Veteran’s contentions are outweighed by the medical evidence, and the claim is denied. 5. Service connection for dental condition due to trauma is denied. New and Material Evidence There was a prior final decision on dental condition due to trauma dated in April 1970. In general, rating decisions that are not timely appealed are final. See 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. Pursuant to 38 U.S.C. § 5108, a finally disallowed claim may be reopened when new and material evidence is presented or secured with respect to that claim. New and material evidence has been presented in the form of a February 2013 VA dental examination report reflecting diagnosis of recurrent decay under crowns 3 and 4. This was not shown at the time of the 1970 rating decision. It was not previously submitted to agency decision-makers so it is new. The teeth finding is material evidence that when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. It raises a reasonable possibility of substantiating the claim. See 38 C.F.R. § 3.156 (a). In determining whether evidence is new and material, the “credibility of the evidence is to be presumed.” Justus v. Principi, 3 Vet. App. 510, 513 (1992). 38 C.F.R. § 3.156 (a) creates a low threshold. Shade v. Shinseki, 24 Vet. App. 110 (2010). The regulation, designed to be consistent with 38 C.F.R. § 3.159 (c)(4), which “does not require new and material evidence as to each previously unproven element of a claim.” See id. The claim is reopened. Service connection The Veteran testified that he seeks service connection for a dental condition due to dental trauma for the following reasons: I got hit in the face with the metal shrapnel and there’s still pieces are still in my jaw. And it dislodged two teeth that they had to operate and pull out. And then pack my whole face gauze and so on. Until I got to the 106th General in Japan. And then both in, I went to the VA in Buffalo, New York, when I retired. And they performed dental work on me. I went to the VA in Phoenix, Arizona, while I was attending business school and they also preformed dental work on me. And then I went to the VA in New Orleans, Louisiana, where they performed dental work on me but not only did, they perform the dental work. They complete did all, all my teeth over. It was a Dr. [P. C.] and a Dr. [H.C.], whose now out in California. And they replaced all my teeth with caps and so on. And when I went to --after Katrina, went to the VA for dental treatment. They told me I wasn’t qualified. Now, I don’t understand how, like, I got hit in the face. In the jaw and I got scars on my face to prove it. That they now after they did all this dental work on me and just denying me dental coverage. And they did all the work as a result of the wounds that I received in Vietnam to my face. The Veteran told the undersigned that he had two teeth removed in service. He stated that the dental issue bothered him right now most of all. He spent a lot of money on dental work. He did not understand why the VA stopped giving him dental treatment, after they had replaced all his teeth. He had been 100 percent disabled in the past but is now rated 90 percent combined. The undersigned discussed generally that there is priority of care at VA and that the 100 percent rating had most likely entitled him to many ancillary benefits and treatments, even if not service-connected, such as dental treatment. Once he dropped below 100 percent he was probably not eligible to be treated for dental issues. The Veteran reported that this was never explained to him, and that he was surprised when told in 2013 that he was just not covered anymore. He felt he never before got a satisfactory answer why. The Veteran’s representative agreed to more thoroughly discuss the concept of how VA dental treatment works and the difference between service connected and non-service connected with the Veteran after the hearing.   Available STRs do not show treatment for any injuries to the teeth though the shrapnel injuries of course are noted. VA examination in February 2013 included the VA dentist’s review of the dental STRs. The VA examiner explained that the STRs stated that no teeth were affected due to the shrapnel wounds. The February 2013 exam itself revealed fully crowned dentition on all arches with bridge replacing teeth 7 through 11. Recurrent decay was present under abutment crowns 3,4. The Veteran had no other symptoms or pathology associated with his teeth or TMJ. However, the Veteran told the examiner that he lost teeth 7 through 11 in a football injury before entering service. He was not in current treatment for dental disorders. There was no history of neoplasm, no difficulty chewing, opening his mouth or talking and no pain, draining or swelling in the oral cavity. He had maximum opening of 48 mm with right and left excursions of 20 mm each, and no pain on function. He was able to do repetitive motion of the TMJ with no pain or loss of range. The examiner diagnosed recurrent decay under crowns 3 and 4 as the only current dental pathology. The conclusion was, “Recurrent decay under crowns 3,4 is not connected to the soft tissue fragment wounds to the right maxilla incurred on 5/24/1969.” In April 1970, VA denied service connection for a dental condition because there was no evidence of a traumatic dental injury for which VA awards compensation. Disability compensation may be provided for certain specified types of service-connected dental disorders. For other types of service-connected dental disorders, the claimant may receive treatment only and not compensation. 38 U.S.C. § 1712; 38 C.F.R. §§ 3.381, 4.150, 17.161. Dental disabilities that may be awarded compensable disability ratings are set forth under 38 C.F.R. § 4.150. These disabilities include chronic osteomyelitis or osteoradionecrosis of the maxilla or   mandible, loss of the mandible, nonunion or malunion of the mandible, loss of the maxilla, nonunion or malunion of the maxilla, limited temporomandibular motion, loss of the ramus, loss of the condyloid or coronoid processes, loss of the hard palate, and loss of teeth due to the loss of substance of the body of the maxilla or mandible without loss of continuity. 38 C.F.R. § 4.150, Diagnostic Codes 9900-9916. Compensation is only available for loss of teeth, where the lost masticatory surface cannot be restored by suitable prosthesis, if such is due to loss of substance of body of maxilla or mandible, but only if such bone loss is due to trauma or osteomyelitis, and not to the loss of the alveolar process as a result of periodontal disease, as such loss is not considered disabling. See 38 C.F.R. § 4.150, Diagnostic Code 9913. Here, no dental records reveal loss of bone of the maxilla or mandible not due to edentulous atrophy or periodontal disease. The Board finds that the record does not show that the Veteran sustained any damage to his maxilla or mandible, or suffered any other impairment involving the mandible, ramus, or maxilla, during service. Service connection for a dental condition is denied because replaceable missing teeth is not a disability for which service connection for compensation purposes may be granted. For these reasons, the Board finds that the claim for service connection for a dental disorder due to trauma, for compensation purposes, must be denied. The Board is sympathic to the Veteran’s claim and assertions upon appeal. After this sympathetic review, however, does not find a basis for compensation under this fact pattern and 38 C.F.R. § 4.150 and further finds that the issue of additional treatment for dental treatment is not before the Board at this time. Indeed, the claim has been exclusively described as one for dental condition due to trauma. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, as the preponderance of the evidence weighs against the claim, that doctrine is not applicable. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Entitlement to a rating in excess of 50 percent for somatic symptom disorder is remanded. The most recent VA examination for this disability occurred in March 2014. Since that time, the Veteran has indicated in December 2020 testimony before the undersigned that his disability has worsened and is more disabling than currently rated. He testified that mentally he felt terrible. When asked about symptoms of this disorder, he explained that now it takes him a while to get out of bed. At the same time, he cannot walk more than about 50 yards without suffering ‘real, real’ problems in his back and legs. This hurts him both physiologically and physically because he used to play football and sports. He used to play with his children and grandchildren but cannot do it anymore. He felt his mental status is now nowhere near what it should be due to constant, continuous pain. He stated that he mostly shuts down and keeps it to himself. He acknowledged he now has thoughts of harming other people when situations arise where people give him a hard time. In light of the Veteran’s statements that his psychiatric disability picture has worsened since his last examination, another examination must be afforded to accurately assess his current level of disability due to PTSD. Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). The Veteran should be provided an opportunity to report for a VA examination to ascertain the current severity and manifestations of somatic symptom disorder. He also reported in December 2020 that he is getting ongoing treatment for this disorder at a VA medical facility, yet the claims folder contains VA treatment records dated through December 2017 with reference to a future appointment in January 2018. Updated VA treatment records should be obtained and associated with the record. 2. Service connection for atrial fibrillation (claimed as heart irregular) to include as secondary to the somatic symptom disorder is remanded. Examination is warranted in this matter as well. The Veteran urges his heart disorder is either proximately due to or aggravated by his psychiatric disorder, thus warranting service connection under the provisions of 38 C.F.R. § 3.310. Alternatively, he theorizes it is related to presumed Agent Orange exposure in Vietnam. VA treatment records dated to December 2017 reflect findings of chronic atrial fibrillation. The Veteran testified however that he now has ischemic heart disease and evidence of such should be in his VA medical record. He has submitted a medical article in support of his secondary service connection theory. The article from Emory news center, Study links post-traumatic stress disorder and cardiovascular disease, cites a study that links PTSD to coronary heart disease using objective measures of heart disease, such as cardiac imaging techniques and clinical histories. We find this potentially relevant as the Veteran’s psychiatric disorder has been variously characterized as reflected in the VA rating decisions as ‘somatic symptom disorder, previously diagnosed as pain disorder associated with both general medical and psychological factors, and formerly evaluated as pain disorder; adjustment disorder with mixed anxiety and depressed mood; PTSD; major depressive disorder’. VA treatment records are potentially not complete, as again they date only to December 2017. This is relevant in view of his testimony that there is ischemic heart disease, since ischemic heart disease is on the list of diseases associated with exposure to certain herbicide agents and thus, presumptive service connection can be established. See 38 C.F.R. § 3.309. Ischemic heart disease as that term is defined is noted as including, but not being limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal's angina. Ischemic heart disease does not include hypertension or peripheral manifestations of arteriosclerosis such as peripheral vascular disease or stroke, or any other condition that does not qualify within the generally accepted medical definition of Ischemic heart disease. Under the circumstances, we find that he should be afforded VA examination to determine the nature of any current heart disorder, and to determine whether there is ischemic heart disease or whether any other current heart disorder is related to service or service-connected psychiatric disorder. The matters are REMANDED for the following action: 1. Obtain the Veteran’s VA treatment records for the period from December 2017 through the present. 2. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected somatic symptom disorder. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. 3. Schedule the Veteran for a VA examination to determine the nature and etiology of his cardiovascular disability, variously diagnosed. The claims file must be reviewed by the examiner and the report should note that review. Based on the examination results and a review of the record, the examiner should provide an opinion on the following: a. Does the Veteran have ischemic heart disease, as included in the definition of per VA regulations? Why or why not?   b. Is it at least as likely as not (50 percent or greater) that the Veteran's current heart disease began during or was otherwise caused by a period of active duty, to include his presumed exposure to Agent Orange? Why or why not? The examiner is hereby advised that ischemic heart disease includes, but is not limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal's angina. Ischemic heart disease does not include hypertension or peripheral manifestations of arteriosclerosis such as peripheral vascular disease or stroke, or any other condition that does not qualify within the generally accepted medical definition of ischemic heart disease. c. Is it at least as likely as not (50 percent or greater) that the Veteran's current heart disease was caused by, or is aggravated by service-connected psychiatric disability? Why or why not? If service-connected psychiatric disability aggravates the current heart disorder, the examiner should identify the percentage of disability which is attributable to the aggravation. See 38 C.F.R. § 3.310. The examiner is asked to consider the Emory article. A complete rationale for any opinion expressed should be provided in a report. If upon completion of the above action the claim remains denied, the case should be returned to the Board. H. N. SCHWARTZ Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board N. RIPPEL 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.