Citation Nr: 21020841 Decision Date: 04/08/21 Archive Date: 04/08/21 DOCKET NO. 16-63 117 DATE: April 8, 2021 REMANDED Entitlement to service connection for residuals of heat stroke is remanded. Entitlement to service connection for hypertension is remanded. Entitlement to service connection for an acquired psychiatric disorder, to include PTSD, is remanded. Entitlement to service connection for psoriasis is remanded. REASONS FOR REMAND The Veteran served on active duty from October 1989 to April 1995 and April 1995 to January 2000, to include service in the Southwest Asia theatre of operations from September 1990 to April 1991. His medals include the Combat Infantry Badge. His discharge from the last period of service has been characterized as dishonorable for VA purposes. This matter comes before the Board of Veterans’ Appeals (Board) from an April 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO).   In January 2021, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record. The Veteran sought service connection for sleeplessness due to combat. Although the RO characterized the claim as service connection for PTSD, the Board has recharacterized the issue on appeal as service connection for an acquired psychiatric disorder, to include PTSD, based on the Veteran’s Board hearing testimony. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). 1.-4. Entitlement to service connection for residuals of heat stroke; hypertension; an acquired psychiatric disorder, to include PTSD; and psoriasis It appears there may be outstanding service treatment records. Although the Veteran’s service treatment records were requested in July 2014, it does not appear that his complete service treatment records have been associated with the claims file. Thus, a remand to obtain any outstanding service treatment records is needed. Further, during the Board hearing, the Veteran testified that he developed a skin rash while performing field training exercises while stationed at Fort Campbell, Kentucky, at which time he was hospitalized and diagnosed with psoriasis; and that he was treated for and diagnosed with heat stroke during his deployment to Saudi Arabia from September 1990 to April 1991. As hospitalization records may be kept separately from other service treatment records, a request for any hospitalization records through official sources should be requested. There may be outstanding medical treatment records. During the Board hearing and April 2014 VA examinations, the Veteran reported he has been treated for sleep problems since approximately 2008; is currently prescribed medications for his sleep problems and diagnosed hypertension; and was previously prescribed anxiety medication on two different occasions. Although some private treatment records are of record, it does not appear that the referenced records are associated with the claims file. Updated VA and private treatment records should be requested. Regarding the claimed psychiatric disorder, an April 2014 VA examiner concluded that the Veteran is not diagnosed with PTSD or any other mental disorder. However, the Veteran subsequently testified at the Board hearing that he suffers from psychiatric symptoms, including depression, insomnia, restlessness and night sweats. Further, private treatment records in April 2014 and March 2015 reflect diagnoses of insomnia and anxiety and a primary medical history of depression. Thus, a new VA examination is warranted to address whether the Veteran has a current psychiatric disorder and whether such is related to service. The matters are REMANDED for the following actions: 1. Request the Veteran’s complete service personnel and service treatment records. Document all requests for information and all responses in the claims file. If the records do not exist or are not available, issue a formal finding of unavailability and notify the Veteran of such. 2. Request through official sources a search for clinical and/or hospital records for the claimed psoriasis while serving at Fort Campbell, KY and the claimed residuals of heat stroke while deployed to Saudi Arabia for his honorable period of active duty from October 1985 to April 1995. If additional information is needed from the Veteran to request such records, the Veteran should be asked to provide it. All efforts to obtain such records should be documented in the claims file. If the requested records do not exist or are not available, issue a formal finding of unavailability and notify the Veteran of such. 3. Ask the Veteran to provide the names and addresses of all medical care providers who have recently treated him for his claimed disabilities. After securing any necessary releases, request any relevant records identified that are not duplicates of those associated with the claims file. In addition, obtain updated VA treatment records. If any requested records are unavailable, the Veteran should be notified of such. 4. After records development is completed and any available records associated with the claims file, schedule the Veteran for a VA mental disorders examination to determine the nature of any psychiatric disorder and obtain an opinion as to whether it is related to the Veteran’s honorable period of active service from October 1985 to April 1995. The claims file should be reviewed by the examiner in conjunction with the examination. All indicated tests should be conducted and the results reported. After reviewing the claims file and examining the Veteran, the examiner should identify all psychiatric disorders present and respond to the following: (a.) Does the Veteran meet the diagnostic criteria for PTSD? Please explain why or why not. (b.) For any diagnosed psychiatric disorder, other than PTSD, opine whether it is at least as likely as not (50 percent probability or greater) that the psychiatric disorder arose during service or is otherwise related to service. The examiner should explain why or why not. In rendering a diagnosis, the examiner is asked to consider insomnia, anxiety and depression, as referenced in private treatment records. The examiner should provide a rationale for the opinions and conclusions expressed.   5. Readjudicate the claims. If the benefits sought on appeal remain denied, issue a supplemental statement of the case. K. A. BANFIELD Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. C. Birder 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.