Citation Nr: 21021522 Decision Date: 04/13/21 Archive Date: 04/13/21 DOCKET NO. 17-66 144 DATE: April 13, 2021 REMANDED Entitlement to a rating in excess of 50 percent for posttraumatic stress disorder (PTSD) is remanded. REASONS FOR REMAND The Veteran served honorably in the United States Army from September 1966 to October 1969. This issue comes before the Board of Veterans’ Appeals (Board) on appeal from an April 2015 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In January 2021, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. The transcript is of record. The Veteran contends that his PTSD symptoms are worse than the rating currently assigned. The Board notes that the Veteran was last afforded a VA examination for compensation and pension purposes in October 2017. Since this examination, the Veteran has stated that his symptoms have worsened. He testified at his Board hearing that (1) his psychiatric medication dosage has increased, (2) he experiences problems controlling his anger, (3) he experiences memory issues, and (4) has had passive thoughts of hurting himself. This evidence suggests that the Veteran's symptoms may have increased in severity since the last VA examination. The VA's duty to assist includes providing a thorough and contemporaneous medical examination, especially where it is necessary to determine the current level of a disability. Peters v. Brown, 6 Vet. App. 540, 542 (1994). As the Veteran was last afforded a VA examination over three and a half years ago and there is evidence demonstrating that his disability may have worsened, a more contemporaneous examination is warranted in order to ensure that the record reflects the current severity of the Veteran's service-connected PTSD. See Caffrey v. Brown, 6 Vet. App. 377, 381 (1994) (determining that Board should have ordered contemporaneous examination of Veteran because a 23-month old exam was too remote in time to adequately support the decision in an appeal for an increased rating); Green v. Derwinski, 1 Vet. App. 121, 124 (1991) (holding that where the record does not adequately reveal the current state of that disability, the fulfillment of the statutory duty to assist requires a thorough and contemporaneous medical examination). Accordingly, a remand is necessary for a new VA examination to determine the current severity of his service-connected PTSD. The matter is REMANDED for the following action: 1. Obtain updated VA and/or private treatment records to the extent possible. If such records are unavailable, the Veteran’s claims file must be clearly documented to that effect and the Veteran notified in accordance with 38 C.F.R. § 3.159(e). (Continued on the next page)   2. Schedule the Veteran for an examination to determine the current severity of his service-connected PTSD using the most recent DBQ examination form. The evidentiary record must be made available to and reviewed by the examiner. The examination report must include a notation that this record review took place. A complete history, including an employment history, should be elicited directly from the Veteran and any tests and studies deemed necessary by the examiner should be conducted. All findings should be reported in detail. G. A. WASIK Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J.T. Massey, Associate Counsel 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.