Citation Nr: 18160488
Decision Date: 12/27/18	Archive Date: 12/26/18

DOCKET NO. 15-15 189
DATE:	December 27, 2018

Entitlement to service connection for post-traumatic stress disorder (PTSD) is granted.
Entitlement to service connection for a left shoulder disability, secondary to service-connected left foot disability, is remanded.
The Veteran’s PTSD is attributable to service.
With resolution of reasonable doubt in the Veteran’s favor, the criteria for entitlement to service connection for PTSD have been met.  38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. §§ 3.303, 3.304, 4.125 (2018).
The Veteran is a Purple Heart recipient having served in Vietnam on active duty from June 1967 to October 1968.
Service Connection
Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service.  38 U.S.C. §§ 1110, 1131.
Service connection may be established for PTSD when there is (1) medical evidence diagnosing the disorder in accordance with 38 C.F.R. § 4.125(a); (2) a link, established by medical evidence, between current symptoms and an in-service stressor; and (3) credible supporting evidence that the claimed in-service stressor occurred.  38 C.F.R. § 3.304(f).
If the evidence establishes that the Veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the Veteran’s service, the Veteran’s lay testimony alone may establish the occurrence of the claimed in-service stressor.
If a stressor claimed by a veteran is related to the veteran’s fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of PTSD and that the Veteran’s symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the places, types, and circumstances of the veteran’s service.  38 C.F.R. § 3.304(f)(3).
Reasonable doubt concerning any matter material to the determination is resolved in the Veteran’s favor.  38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102.
Turning to the evidence of record, the evidence shows that the Veteran received a private psychiatric evaluation in August 2012 in which the Veteran reported having served in Vietnam and being wounded in action.  He reported intrusive recollections of his combat experiences to include being involved in ambush missions, stepping on a mine during the mission, and being exposed to enemy rocket and mortar fire, mines, snipers, and booby traps.  The Veteran reported that he has flashbacks, depressed mood, anxiety, panic symptoms, difficulty with concentrating, and obsessive thinking.  After examining the Veteran, the examiner diagnosed the Veteran with PTSD and found that the Veteran’s distress appears to be related to and likely caused by his combat experiences in Vietnam.  
Alternatively, in a March 2013 VA examination for PTSD, the Veteran was not diagnosed with a mental disorder.  Rather, the examiner found that the Veteran’s symptoms did not meet the criteria for a PTSD diagnosis under DSM-IV criteria.  Specifically, the examiner found that the Veteran met the PTSD criteria A-E, but that his symptoms of depressed mood, anxiety, and difficulty understanding complex commands were not associated with any mental health diagnosis.   
In evaluating the afore-mentioned medical opinions, the Board recognizes that the opinions are contrasting with regard to whether the Veteran has a diagnosis of PTSD; however, the Veteran’s military personnel records show that the Veteran received the Vietnam Service Medal, the Combat Infantry Badge, and a Purple Heart.  Given this evidence, it is clear that the Veteran served in combat.  The Board also finds the evidence is persuasive in corroborating the August 2012 examiner’s diagnosis of PTSD due to the Veteran’s combat experience.   
Given the above, the Board finds that the evidence for and against the claim of entitlement to service connection for PTSD is at least in equipoise.  Therefore, all reasonable doubt must be resolved in favor of the Veteran and entitlement to service connection PTSD is warranted. 38 U.S.C. § 5107 (b) (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990).
Service connection for left shoulder
The Veteran seeks service connection for a left shoulder disability.  Specifically, the Veteran asserts that his service-connected left foot causes instability and lack of balance which has resulted in injury to numerous parts of his body, including his shoulders.  A December 2011 x-ray of the Veteran’s shoulders showed an absent distal clavicle on the left which may be post-surgical or posttraumatic.  In his VA Form 9, the Veteran also suggested that his left shoulder injury may have been caused by his other service-connected disabilities, to include bilateral lower extremity radiculopathy, bilateral hip degenerative joint disease, and a back disability.  Given that the Veteran has not been afforded a VA examination for this claim, an examination is warranted.  The Board notes the duty to assist may include providing a medical examination when such is necessary to make a decision on the claim.  See 38 U.S.C. § 5103A (d)(2); 38 C.F.R. §§ 3.159 (c)(4), 3.326(a).  
Further, the Veteran reported having surgery to his left shoulder due to a fall, and reiterated such in his VA Form 9, noting that the surgery took place in 2004.  Although VA attempted to retrieve these records, a response was received indicating that records were not available for 2004.  On remand, the AOJ should clarify the dates of treatment to the Veteran’s left shoulder, and attempt to obtain the records again if different information is provided.  
The matter is REMANDED for the following action:
1. Obtain all VA treatment records for the Veteran dated from March 2015 to the present and associate the same with the Veteran’s claim file.
2. Ask the Veteran to clarify his private treatment providers and dates of treatment for his left shoulder, so that any outstanding records may be obtained.  The RO must make two (2) attempts to obtain any private records identified, unless the first attempt demonstrates that further attempts would be futile.
If private records are identified, but not obtained, the RO must notify the Veteran of (1) the identity of the records sought, (2) the steps taken to obtain them, (3) that the claim will be adjudicated based on the evidence available, and (4) that if the records are later obtained, the claim may be readjudicated.
3. Schedule the Veteran for a VA examination for his asserted left shoulder disability.  The examiner should first identify whether the Veteran has a current disability for his left shoulder. 
If the examiner identifies a disability, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or better) that the identified left shoulder condition is caused or aggravated by the Veteran’s service-connected left foot disability, or any other service-connected disability.
Aggravation is defined as a worsening beyond the natural progression of the disability.
(Continued on the next page)
A complete rationale must be provided for any opinion offered.
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	K. Laffitte, Associate Counsel 

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