Citation Nr: 22017736 Decision Date: 03/26/22 Archive Date: 03/26/22 DOCKET NO. 17-59 957 DATE: March 26, 2022 REMANDED Entitlement to service connection for a psychiatric disorder, including posttraumatic stress disorder (PTSD) and major depressive disorder (MDD), is remanded. Entitlement to service connection for a low back disability is remanded. Entitlement to service connection for a pulmonary condition, including bronchitis, is remanded. Entitlement to service connection for cold injury residuals of the bilateral hands is remanded. Entitlement to service connection for sinusitis and/or allergic rhinitis is remanded. Entitlement to service connection for a gastrointestinal condition, claimed as irritable bowel syndrome (IBS), is remanded. REASONS FOR REMAND The Veteran served honorably on active duty in the U.S. Marine Corps from April 1992 to February 1996. These matters come before the Board of Veterans' Appeals (Board) on appeal from October 2016 and November 2016 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a hearing before the undersigned Veterans Law Judge in October 2021. A transcript of the hearing is of record. 1. Entitlement to service connection for a psychiatric disorder, including PTSD and MDD, is remanded. In support of his claim for PTSD, the Veteran states that during a rifle training exercise, a fellow recruit took his own life. That experience deeply affected him. See October 2021 Hearing Transcript. In a November 2016 memorandum for the file, the RO determined that there was insufficient information to attempt to verify the Veteran's reported stressor. See 38 C.F.R. § 3.304(f). In a June 2016 statement (VA Form 21-0781), the Veteran wrote that the event occurred in June 1992 at Camp Pendleton. At that time, he was assigned to the 1st FSSG (Force Service Support Group). He did not provide the service member's name in that statement, explaining at the Board hearing that he does not remember it. Because he did not provide the individual's name, the RO did not attempt to verify the reported stressor. See November 2016 VA Memo. The Board finds that although the Veteran does not remember the name of the person who committed suicide, he has provided enough information that an effort should be made to verify it by submitting a request to the Military Records Research Center (MRRC). The MRRC may be able to verify that a suicide by a Marine Corps recruit occurred in June 1992 at Camp Pendleton as related by the Veteran. The VA treatment records show that the Veteran has been diagnosed with MDD, and possible PTSD ( "r/o PTSD"). The Board finds that a VA examination is warranted to help determine whether he has a current psychiatric disorder linked to his active service. If his reported stressor is verified, an opinion as to whether his PTSD symptoms are linked to that stressor should also be obtained. Finally, the Veteran's service personnel records have not been obtained. These records must be obtained and added to the file, to the extent possible. 2. Entitlement to service connection for a low back disability is remanded. The Board finds that a VA examination and medical opinion are warranted to help make an informed decision on the claim for a back disability. The Veteran states that he initially experienced low back pain during service when participating in a training exercise that involved running with a heavy pack, as described in his hearing testimony. He stated that his back hurt all the time during service, but that he did not get treatment for it due to the pressure of the military culture, which discouraged seeking medical attention. The Veteran has submitted a December 2021 letter from a private treating chiropractor, M. Adigun, who wrote that the Veteran was seen for treatment for mid and low back pain in December 2021. The letter states that he reported an initial injury to his back in active service, and that he has had persistent back pain since then. The chiropractor stated that the Veteran's chronic back pain may be related to his initial in-service injury. The service treatment records reflect that in October 1994, the Veteran complained of pain in his sternum radiating through his back. He stated he had been running and lifting weights that morning. The assessment was, "R/O chest/back pain." The service treatment records do not show subsequent treatment for back issues. On remand, the Veteran should be asked to authorize the release of his treatment records from M. Adigun. After those records have been obtained (or it has been determined that further efforts to obtain them are not warranted), a VA examination should be performed and an opinion provided as to the likelihood that the Veteran has a current back disability related to service. 3. Entitlement to service connection for a pulmonary condition, including bronchitis, is remanded. The Board finds that a VA examination and medical opinion are warranted to help make an informed decision on the claim for a pulmonary condition, including chronic bronchitis. The service treatment records show that the Veteran was assessed with bronchitis on several occasions, with symptoms such as coughing and wheezing of the lungs. Post-service evidence includes a February 2015 private treatment record reflecting a diagnosis of bronchitis. More recently, a January 2019 VA treatment record shows that he complained of a cough that was not getting better. He was diagnosed with bronchitis. The Board finds there is at least an indication that he has a current pulmonary condition related to the respiratory symptoms and diagnoses of bronchitis during service. Accordingly, a VA examination should be performed, and an opinion obtained as to the likelihood that the Veteran's has a current pulmonary condition, such as chronic bronchitis, linked to his in-service episodes of bronchitis. See McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). 4. Entitlement to service connection for cold injury residuals of the bilateral hands is remanded. The Board finds that a VA examination and medical opinion are warranted to help make an informed decision on the claim for residuals of cold injuries to the bilateral hands. A March 1993 service treatment record reflects that the Veteran was seen with complaints of tingling and numbness in the fingers after wearing wet gloves for 1.5 hours that morning. No abnormalities were noted on examination of the hands. He was assessed with chilblains of both hands. A March 2020 VA treatment record reflects that the Veteran reported hand pain, and was assessed with arthralgia in his hands. In a January 2021 letter, a treating physician, R. Moore, stated that the Veteran was seen for longterm finger and hand numbness, along with intermittent coolness in his fingertips. The physician found that these symptoms stemmed from cold weather training in active service, stating that the Veteran has experienced cold weather residual symptoms in both hands since then, which have become progressively more frequent. The Board finds that the January 2021 private medical opinion is not sufficient to make an informed decision, as it does not account for the fact that the March 1993 service treatment record indicates that no abnormalities were found on examination. It also does not account for the fact that subsequent service treatment records, including the separation report of medical history, private treatment records dating from about 2013 to 2017, and VA treatment records dating from February 2018 (when the Veteran was first seen at VA) to January 2021 do not show complaints of hand numbness or intermittent coolness, including when he was seen for hand pain in March 2020. The Board also notes that a January 2013 private treatment record reflects follow-up for a right hand fracture. No symptoms are noted in that record, and the history of that fracture is not described. There are no other treatment records pertaining to a hand fracture. Accordingly, a VA examination should be performed to assess whether the Veteran has current residuals of cold injuries to his hands, and if so, whether they are linked to the symptoms following cold exposure described in the March 1993 service treatment record. The Veteran should also be asked to authorize the release of his treatment records from R. Moore. 5. Entitlement to service connection for sinusitis and/or allergic rhinitis is remanded. The Board finds that a VA examination and medical opinion are warranted to help make an informed decision on the claim for sinusitis, which the Board has expanded to include allergic rhinitis based on a September 2020 private treatment record showing a diagnosis of that condition. The service treatment records show that in July 1992, the Veteran was seen for symptoms that included mild nasal drainage. He had positive maxillary sinus taps. In October 1993, he was seen for virus symptoms, at which time it was noted that he had positive pressure build up in his maxillary sinuses. In the January 1996 report of medical history at separation, the Veteran endorsed a history of sinusitis. It was noted that he had mild sinus problems in the past, which had since resolved. More recent private treatment records show treatment for symptoms including congestion, rhinorrhea, and sinus pain. See October 2015 Private Treatment Record. Private treatment records dated in October 2015 and September 2020 show diagnoses of allergic rhinitis. The Board finds that a VA medical examination and opinion are warranted to assess whether the Veteran's rhinitis and/or sinusitis (if diagnosed) is linked to his in-service symptoms. The Board notes that in a June 2021 written statement (VA Form 21-4138) and at the October 2021 Board hearing, the Veteran stated that he was in Kuwait for a 30-day training exercise during active service. VA regulation provides, in relevant part, for a presumption of service connection for certain chronic diseases, including rhinitis and sinusitis (to include rhinosinusitis) based on service in the Southwest Asia theater of operations (as defined in 38 C.F.R. § 3.317(e)(2)) during the Persian Gulf War (as defined in 38 C.F.R. § 3.2(i)) under the circumstances specified in the regulation. 38 C.F.R. § 3.320. The Board has not found documentation of service in Kuwait. As discussed above, the Veteran's service personnel records are not in the file, and the Board's remand directives include an instruction to obtain those records, which may show that he was stationed in Kuwait. At the hearing, the Veteran's representative stated that his service treatment records include an entry that mentions "exposure to asbestos while he was in Kuwait." The Board has located a July 1993 asbestos questionnaire, but it does not mention Kuwait. If the Board has somehow overlooked that evidence, the Veteran or his representative are invited to identify it for the agency of original jurisdiction (AOJ) to consider. If the AOJ finds that the Veteran had service in Kuwait, it should determine whether the criteria for presumptive service connection are met for his rhinitis and/or sinusitis (if the latter condition is shown). 6. Entitlement to service connection for a gastrointestinal condition, claimed IBS, is remanded. The Veteran claims service connection for a gastrointestinal condition as a manifestation of an undiagnosed illness or medically unexplained chronic multisymptom illnesses (MUCMI) based on service in the Southwest Asia theater of operations. See 38 C.F.R. § 3.317(a)(1); 38 U.S.C. § 1117. As discussed, the Board has not located evidence in the file showing service in Kuwait, where he states he was stationed for a 30-day training period. If evidence of service in Kuwait is obtained on remand, the AOJ should arrange for a Gulf War examination to assess whether he has signs and symptoms of an undiagnosed illness or MUCMI with gastrointestinal manifestations. The Veteran, through his representative, stated at the hearing that the Gulf War examination should also address his recurring bronchitis and upper respiratory symptoms. (Continued on next page) The matters are REMANDED for the following action: 1. Obtain the Veteran's service personnel records and add them to the claims file. 2. Request the Veteran to authorize the release of his treatment records from M. Adigun at Extra Wellness Center, LLC. He should also be invited to submit these records himself. 3. Request the Veteran to authorize the release of his treatment records from R. Moore at Village Medical. He should also be invited to submit these records himself 4. Request the Veteran to identify and authorize the release of the treatment records pertaining to a right hand fracture that he sustained in 2012 or 2013 (he had follow-up treatment in January 2013). 5. Add to the file any outstanding VA treatment records pertaining to the Veteran dated since June 2021. 6. Request the MRRC to determine whether it can verify that a U.S. Marine Corps recruit committed suicide at Camp Pendleton in June 1992. It should also provide any information it has as to the circumstances of that event. While the Veteran does not remember the name of the individual, that information might not be necessary to verify whether a suicide occurred as he states. The Veteran was assigned to the 1st FSSG (Force Service Support Group). Presumably, the individual who committed suicide was in the same unit. 7. After the above development has been completed to the extent possible, arrange for a VA psychiatric examination. Based on examination of the Veteran and review of the claims file, the examiner should provide an opinion as to the likelihood that the Veteran has a psychiatric disorder, including major depressive disorder, linked to an in-service disease, injury, or event. If the claimed in-service stressor is verified and a PTSD diagnosis is established, the examiner should also provide an opinion as to the likelihood that the Veteran's PTSD symptoms are linked to that stressor. 8. Arrange for a VA examination of the Veteran's thoracolumbar spine. Based on examination of the Veteran and review of the claims file, the examiner should provide an opinion as to the likelihood that the Veteran has a current back disability related to service, including marching or running with a heavy pack. In that regard, the examiner should discuss the October 1994 record, which reflects that the Veteran complained of pain in his sternum radiating through his back. He stated that he was running and lifting weights that morning. 9. Arrange for a VA pulmonary examination. Based on examination of the Veteran and review of the claims file, if the examiner finds that the Veteran has a current pulmonary condition such as chronic bronchitis, the examiner should provide an opinion as to the likelihood that it is linked to the Veteran's episodes of bronchitis during active service. 10. Arrange for a VA examination of the Veteran's hands. Based on examination of the Veteran and review of the file, the examiner should provide an opinion as to the likelihood that the Veteran has current residuals of cold injuries, in light of the March 1993 service treatment record showing that he was seen with complaints of tingling and numbness in the fingers after wearing wet gloves for 1.5 hours that morning. He was assessed at the time with chilblains of both hands. 11. Arrange for a VA sinusitis/rhinitis examination. The examiner is advised that the Veteran has previously been diagnosed with allergic rhinitis. Based on examination of the Veteran and review of the file, the examiner should provide an opinion as to the likelihood that the Veteran's allergic rhinitis and/or sinusitis (if diagnosed) is linked to his in-service episodes of upper respiratory symptoms, which included sinus issues. Specifically, in July 1992, he was seen for symptoms that included mild nasal drainage. He had positive maxillary sinus taps. In October 1993, he was seen for virus symptoms, at which time it was noted that he had positive pressure build up in his maxillary sinuses. In the January 1996 report of medical history at separation, he endorsed a history of sinusitis. It was noted that he had mild sinus problems in the past, "now resolved." 12. If the Veteran's service in Kuwait is confirmed, the AOJ should also determine whether presumptive service connection for rhinitis and/or sinusitis (if diagnosed) may be established under 38 C.F.R. § 3.320 based on his service in the Southwest Asia theater of operations. 13. If the Veteran's service in Kuwait is confirmed, arrange for a Gulf War examination to assess whether the Veteran has an undiagnosed illness or MUCMI manifested by signs and symptoms including gastrointestinal symptoms and/or pulmonary and upper respiratory symptoms. P.M. DILORENZO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Rutkin, 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.