Citation Nr: 0005167 Decision Date: 02/28/00 Archive Date: 03/07/00 DOCKET NO. 98-11 518 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Reno, Nevada THE ISSUES 1. Entitlement to service connection for recurrent leg and arm pain. 2. Entitlement to service connection for post-traumatic stress disorder (PTSD). 3. Entitlement to an evaluation in excess of 10 percent for dermatitis. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Jeffrey J. Schueler, Counsel INTRODUCTION The appellant had active service from May 1970 to January 1972. He also had active duty for training from July 8 to July 23, 1972. This matter comes to the Board of Veterans' Appeals (Board) from decisions of the Department of Veterans Affairs (VA) Reno Regional Office (RO). In a February 1998 decision, the RO denied the appellant's application to reopen a previously denied claim of service connection for recurrent leg and arm pain. In July 1998, the RO denied service connection for PTSD and a rating in excess of 10 percent for service-connected dermatitis. The appellant disagreed with the determinations and this appeal ensued. With respect to the claim of service connection for recurrent leg and arm pain, the RO previously denied that claim in an August 1994 rating decision. The appellant did not file a notice of disagreement, so that decision became final about one year later. In a November 1997 statement, he filed a claim to reopen the final August 1994 rating decision. For the reasons discussed below, the Board will grant the application to reopen the claim. The issue for appellate review is, therefore, as stated on the title page of this decision. With respect to the claim of service connection for PTSD, that claim was denied in a September 1995 rating decision. Although as noted above the RO treated the claim herein at issue as an initial one for service connection, it is properly an application to reopen the final September 1995 decision. Thus, the proper issue is whether the appellant has submitted new and material evidence to reopen that final decision. However, for the reasons discussed below the Board will grant the application to reopen the claim. The issue for appellate review is, therefore, as stated on the title page of this decision. FINDINGS OF FACT 1. The additional evidence concerning recurrent leg and arm pain received into the record after August 1994 is probative and material, as it bears directly and substantially on the specific matter at hand. 2. The additional evidence concerning PTSD received into the record after September 1995 is probative and material, as it bears directly and substantially on the specific matter at hand. 3. No competent evidence has been submitted linking the post-service findings of recurrent leg and arm pain to service. 4. Competent evidence has been submitted linking the post- service findings of PTSD to service. CONCLUSIONS OF LAW 1. The appellant has submitted new and material evidence to reopen a claim of entitlement to service connection for recurrent leg and arm pain. 38 U.S.C.A. § 5108 (West 1991); 38 C.F.R. § 3.156(a) (1999). 2. The appellant has submitted new and material evidence to reopen a claim of entitlement to service connection for PTSD. 38 U.S.C.A. § 5108 (West 1991); 38 C.F.R. § 3.156(a) (1999). 3. The claim of service connection for recurrent leg and arm pain is not well grounded. 38 U.S.C.A. § 5107(a) (West 1991). 4. The claim of service connection for PTSD is well grounded. 38 U.S.C.A. § 5107(a) (West 1991). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Whether New and Material Evidence Has Been Submitted to Reopen the Claims of Service Connection for Recurrent Leg and Arm Pain and PTSD In an August 1994 rating decision, the RO denied the appellant's claim of service connection for recurrent leg and arm pain. The RO notified him of that decision in a September 13, 1994 letter. In a September 1995 rating decision, the RO denied as not well grounded the claim of service connection for PTSD. The RO notified the appellant of that determination in an October 2, 1995 letter. These rating decisions became final at the expiration of the one- year period following notice thereof. 38 C.F.R. §§ 3.104(a), 20.302(a). Final decisions of the RO may not be reopened in the absence of new and material evidence. If new and material evidence is submitted, the claim will be reopened and adjudicated on the merits. 38 U.S.C.A. § 5108. New and material evidence means evidence not previously submitted to agency decisionmakers which bears directly and substantially on the specific matter under consideration, which is neither cumulative nor redundant, and which by itself or in connection with evidence previously assembled is so significant that it must be considered in order to fairly decide the merits of the claim. 38 C.F.R. § 3.156(a). Whether new and material evidence is submitted is a jurisdictional test, with the Board being required to reopen if such evidence is submitted and prohibited from reopening and considering the claim if such evidence is not submitted. Barnett v. Brown, 83 F.3d 1380, 1383-84 (Fed. Cir. 1996); Winters v. West, 12 Vet. App. 203, 206-07 (1999). VA must (1) determine whether the appellant has presented new and material evidence in order to have a finally denied claim reopened; (2) if so, determine whether the reopened claim is well grounded based upon all the evidence of record, presuming its credibility; and (3) if the claim is well grounded, evaluate the merits of the claim after ensuring that VA's duty to assist has been fulfilled. Elkins v. West, 12 Vet. App. 209, 214 (1999); Winters, 12 Vet. App. at 206- 07. Thus, the first determination is whether the appellant has submitted new and material evidence. New evidence that was not likely to convince the Board to alter its previous decision could be material if it provided a more complete picture of the circumstances surrounding the origin of an injury or disability, even where it would not eventually convince the Board to alter its rating decision. Hodge v. West, 155 F.3d 1356, 1363 (Fed. Cir. 1998); Elkins, 12 Vet. App. at 214. The reopening standard provides for judgment as to whether new evidence bears directly or substantially on the specific matter and is so significant that it must be considered to fairly decide the merits of the claim. Fossie v. West, 12 Vet. App. 1, 4 (1998). See also Evans v. Brown, 9 Vet. App. 273, 284-85 (1995) (new and material evidence must be presented or secured since the time the claim was finally disallowed on any basis and need be probative of only each element that was a specified basis for the last disallowance). With respect to the application to reopen the claim of service connection for recurrent leg and arm pain, since August 1994 the record includes various clinical and examination reports discussing symptomatology relevant to this claim. These documents address factual issues pertaining to the reason for the RO's denial of the claim, namely the lack of evidence showing neurological abnormalities resulting in the appellant's intermittent pain in the legs and arms. Thus, the Board determines that the additional evidence is new and material as it may provide a more complete picture of the circumstances surrounding the origin of the claimed disability. As for the application to reopen the claim of service connection for PTSD, the RO denied that claim in September 1995 because the record did not include evidence substantiating his claimed stressors or linking PTSD to any presumed stressor. Since September 1995, the RO has received into the record several documents suggesting such a link. For example, a September 1994 VA clinical record, received in December 1998, indicated that PTSD had its approximate onset in February 1971, about the time the appellant served in Vietnam. This additional evidence addresses the factual issues pertaining to the reason for the RO's denial of the claim. The Board therefore determines that this additional evidence is new and material because it may provide a more complete picture of the circumstances surrounding the origin of the claimed disability. II. Whether the Reopened Claims of Service Connection for Recurrent Leg and Arm Pain and PTSD Are Well Grounded Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. As the appellant served continuously for 90 days or more during a period of war or during peacetime after December 31, 1946, arthritis and psychosis manifest to a degree of 10 percent within a year from the date of termination of such service is presumed to have been incurred in service, even without evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. The threshold question that must be resolved with regard to a claim is whether the appellant has presented evidence of a well-grounded claim. See 38 U.S.C.A. § 5107(a); Grottveit v. Brown, 5 Vet. App. 91, 92-93 (1993); Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992). Generally, a well-grounded claim requires competent medical evidence of a current disability, lay or medical evidence of incurrence or aggravation of a disease or injury in service, and competent medical evidence of a nexus, or link, between the in-service injury or disease and the current disability. Epps v. Gober, 126 F.3d 1464, 1468 (Fed. Cir. 1997); Caluza v. Brown, 7 Vet. App. 498, 506 (1995). A well-grounded claim of service connection for PTSD requires medical evidence of a current disorder, lay evidence, presumed credible, of an in-service stressor, and medical evidence linking the two. Gaines v. West, 11 Vet. App. 353, 357 (1998); Cohen (Douglas) v. Brown, 10 Vet. App. 128 (1997). A Recurrent Leg and Arm Pain Secondary to Agent Orange Exposure The appellant contends that he has recurrent leg and arm pain related to his service in Vietnam. Service connection may be established under either of two alternative theories. First, the appellant can show a link between his current disorder and symptomatology in service (direct service connection). Second, he may utilize the presumption contained in 38 C.F.R. §§ 3.307(a) and 3.309(e). Under either theory, he must first establish that the claim is well grounded. The facts relevant to the claim are as follows: ? Service medical records are silent as to any disorder affecting the arms or legs. On January 1972 separation examination, the appellant reported no history of disorder affecting the arms and legs; the examiner noted normal upper extremity and lower extremity on clinical evaluation. ? VA examination in July 1974 revealed no swelling, deformity, or limitation of motion in any joint. ? VA clinical records in December 1991 showed right leg pain for the previous five years. ? VA clinical records in May 1993 indicated complaints of left leg pain and records in July 1993 noted complaints of intermittent pain in the extremities. VA clinical records in September 1993 revealed complaints of deep thigh pain; an examiner noted the possibility of somatization. VA clinical records in November 1993 showed complaints of thigh pain. ? VA neurologic examination in April 1994 revealed complaints of intermittent pain and weakness in the lower extremities, hips, and arms. The impression was no neurologic abnormalities. ? In May, September, and October 1996 VA clinical records, it was noted the appellant complained of burning sensation and peripheral neuropathy intermittently since service in Vietnam more than 20 years previously. ? VA clinical records from November 1994 to September 1998 noted complaints of transient pain and tingling in the arms, thigh, and shoulder; pain, weakness, and numbness the lower extremities, including chronic knee pain; and pain, weakness, and numbness in the upper extremities. ? In an undated statement, a VA physician stated that the appellant had been followed for recurrent weakness and paralysis of the arms and legs. ? The appellant testified at a November 1998 hearing that he had recurrent leg and arm pain and that a VA physician informed him that the symptoms were related to exposure to herbicide agents in Vietnam. ? VA clinical records in February and May 1999 indicated that the appellant complained of numbness in his extremities. As to the first theory, the record clearly documents current leg and arm pain beginning in December 1991, as well as the appellant's allegations of incurrence of these symptoms in service, thereby satisfying the first and second elements of a well-grounded claim. As for the third element of a well- grounded claim, however, only two documents noted above discuss the onset of the complaints. VA clinical records in December 1991 showed right leg pain for the previous five years, which would place the onset of the symptoms in 1986, still about 14 years after the appellant separated from service. In a May 1996 VA clinical record, it was noted that the appellant complained of a burning sensation and peripheral neuropathy intermittently since his service in Vietnam more than 20 years previously. But this evidence represents information simply recorded by a medical examiner, unenhanced by any additional medical comment by that examiner. It cannot constitute competent medical evidence. LeShore v. Brown, 8 Vet. App. 406, 410 (1995). Thus, to the extent that this clinical report based a finding on a recitation by the appellant of his own medical history, the information is not probative evidence as to the etiology of the disorder. Additionally, there is no evidence between service and the first showing of the claimed symptomatology in December 1991 to suggest a continuity of symptomatology. See 38 C.F.R. § 3.303(b); Savage v. Brown, 10 Vet. App. 488, 495 (1997). As the evidence is not probative, it cannot form the basis of competent medical evidence. Thus, the Board must determine that the appellant has not submitted competent medical evidence needed to satisfy the third and final element of a well-grounded claim of direct service connection. As to the second theory, a claimant who, during active service, served in the Republic of Vietnam during the Vietnam era and has a disease listed at § 3.309(e) shall be presumed to have been exposed during such service to a herbicide agent, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. See 38 U.S.C.A. § 1116; 38 C.F.R. § 3.307(a). A "herbicide agent" is a chemical in a herbicide used in support of the U.S. and allied military operations in the Republic of Vietnam during the Vietnam era. 38 C.F.R. § 3.307(a)(6)(i). "Service in the Republic of Vietnam" includes service in the waters offshore and service in other locations if the conditions of service involved duty or visitation in the Republic of Vietnam. 38 C.F.R. §§ 3.307(a)(6)(iii), 3.313. The "Vietnam era" is the period beginning on February 28, 1961 and ending on May 7, 1975, inclusive, in the case of a veteran who served in the Republic of Vietnam during that period. 38 C.F.R. § 3.2(f). The evidence of record reveals the appellant had service in Vietnam as he received the Vietnam Service Medal and Vietnam Campaign Medal, both of which signify his service in the Republic of Vietnam. The record overwhelmingly supports the conclusion that he served in Vietnam within the appropriate period, and thereby had qualifying Vietnam service. 38 C.F.R. §§ 3.2(f), 3.307(a)(6)(iii), 3.313(a). Because the appellant is presumed to have been exposed to a herbicide agent during active military, naval, or air service, the following diseases shall be service-connected if the requirements of 38 C.F.R. § 3.307(a)(6) are met, even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 C.F.R. § 3.307(d) are also satisfied: chloracne or other acneform disease consistent with chloracne; Hodgkin's disease; non-Hodgkin's lymphoma; porphyria cutanea tarda; multiple myeloma; acute and subacute peripheral neuropathy; prostate cancer; respiratory cancers (cancers of the lung, bronchus, larynx, or trachea); and soft-tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). The term "soft-tissue sarcoma" includes the following: adult fibrosarcoma; dermato-fibrosarcoma protuberans; malignant fibrous histiocytoma; liposarcoma; leiomyosarcoma; epithelioid leiomyosarcoma (malignant leiomyoblastoma); rhabdomyosarcoma; ectomesenchymoma; angiosarcoma (hemangiosarcoma and lymphangiosarcoma); proliferating (systemic) angioendotheliomatosis; malignant glomus tumor; malignant hemangiopericytoma; synovial sarcoma (malignant synovioma); malignant giant cell tumor of tendon sheath; malignant schwannoma, including malignant schwannoma with rhabdomyoblastic differentiation (malignant Triton tumor), glandular and epithelioid malignant schwannomas; malignant mesenchymoma; malignant granular cell tumor; alveolar soft part sarcoma; epithelioid sarcoma; clear cell sarcoma of tendons and aponeuroses; extraskeletal Ewing's sarcoma; congenital and infantile fibrosarcoma; and malignant ganglioneuroma. 38 C.F.R. § 3.309(e). The Secretary has determined that there is no positive association between exposure to herbicides and any other condition for which he has not specifically determined a presumption of service connection is warranted. 61 Fed. Reg. 41,446 (1996); 59 Fed. Reg. 341-46 (1994). The appellant is not, though, precluded from establishing service connection with proof of actual direct causation. See Combee v. Brown, 34 F.3d 1039, 1041-42 (Fed. Cir. 1994). The initial concern raised by the appellant's allegation that he was exposed to herbicide agents in Vietnam is whether he currently has a disorder listed at 38 C.F.R. § 3.309(e), as is required to prevail in a presumptive service connection claim based on such exposure. The Board reasserts its acknowledgment of the appellant's service in Vietnam. The record includes competent evidence of the appellant's complaints of recurrent leg and arm pain. These complaints, though, are not a disorder listed at 38 C.F.R. § 3.309(e). In light of these findings, the Board cannot conclude that the appellant has a disorder listed at 38 C.F.R. § 3.309(e) that can be presumptively related to herbicide exposure in Vietnam. Service connection may still be established with proof of actual direct causation. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(d); Combee, 34 F.3d at 1041-42. Notations of recurrent leg and arm pain in the clinical and examination records began in December 1991, about 19 years after separation from service. The service medical records and the July 1974 VA examination report do not identify any recurrent leg or arm abnormality. For the most part, the remaining evidence summarized above identifies current symptomatology without reference to the origin of those symptoms. The appellant testified in November 1998 that a VA physician told him that his symptomatology was related to his exposure to Agent Orange in Vietnam. The record includes clinical and hospital records from the VA facility named by the appellant. Such records do not include any finding by a physician linking the current symptoms to the presumed in-service exposure to a herbicide agent. Thus, the record fails to establish any etiologic link between service and the current findings, or between these findings and any exposure to herbicide agents in service. The only opinion of record linking the appellant's current symptomatology with service or with exposure to herbicide agents in service is that of the appellant himself. Generally, statements prepared by lay persons, who are ostensibly untrained in medicine, cannot constitute competent medical evidence to render a claim well grounded. A lay person can certainly provide an eyewitness account of his/her visible symptoms. Layno v. Brown, 5 Vet. App. 465, 469 (1994).; Moray v. Brown, 5 Vet. App. 211, 214 (1994). However, the capability of a witness to offer such evidence is different from the capability of a witness to offer evidence that requires medical knowledge. For the most part, a witness qualified as an expert by knowledge, skill, experience, training, or education must provide medical testimony. Espiritu v. Derwinski, 2 Vet. App. 492, 494-95 (1992). The record does not show that the appellant is trained to provide expert medical testimony. On review of the record, the appellant's claim of service connection for recurrent leg and arm pain, including as secondary to herbicide exposure, is not well grounded. Absent competent evidence of nexus between current symptomatology and service, or exposure to a herbicide agent in service, the claim is not well grounded. As the claim is not well grounded, VA is under no duty to assist the appellant in further development of the claim. 38 U.S.C.A. § 5107(a). B. PTSD The record includes a September 1996 VA hospital report revealing a diagnosis of PTSD, thus satisfying the first element of a well-grounded claim. The appellant contends that he experienced several stressors in service in Vietnam, including the killing of a Vietnamese boy and the suicide of a fellow soldier. The truthfulness of this evidence must be presumed when determining whether a claim is well grounded, satisfying the second element of a well-grounded claim. King v. Brown, 5 Vet. App. 19 (1993). The September 1996 VA hospital report included a discussion of the stressors, on which the diagnosis of PTSD was based, satisfying the final element of a well-grounded claim. As the claim is well grounded, VA has a duty to assist the appellant in developing facts pertinent to the claim. 38 U.S.C.A. § 5107(a). Actions pursuant thereto are addressed in the Remand below. ORDER New and material evidence having been submitted in support of the claim of service connection for recurrent leg and arm pain, the claim is reopened. New and material evidence having been submitted in support of service connection for PTSD, the claim is reopened. Service connection for recurrent leg and arm pain is denied. The claim of entitlement to service connection for PTSD is well grounded. REMAND Prior to March 7, 1997, service connection for PTSD required medical evidence establishing a clear diagnosis of the condition, credible supporting evidence that the claimed in- service stressor actually occurred, and a link, established by medical evidence, between current symptoms and the claimed in-service stressor. If the claimed stressor was related to combat, service department evidence that the appellant engaged in combat or that he was awarded a combat citation would be accepted, absent of evidence to the contrary, as conclusive evidence of the claimed in-service stressor. 38 C.F.R. § 3.304(f) (1997). See Cohen, 10 Vet. App. at 136. Effective on and after March 7, 1997, service connection for PTSD required medical evidence diagnosing the condition in accord with 38 C.F.R. § 4.125(a); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. If the evidence established that the appellant engaged in combat with the enemy and the claimed stressor was related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor was consistent with the circumstances, conditions, or hardships of the veteran's service, the appellant's lay testimony alone could establish the occurrence of the claimed in-service stressor. See 64 Fed. Reg. 32,807-08 (June 18, 1999) (codified at 38 C.F.R. § 3.304(f) (1999)) and 38 C.F.R. § 4.125 (requiring PTSD diagnoses to conform with the criteria in AMERICAN PSYCHIATRIC ASSOCIATION, DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS (4th ed. 1994) (DSM-IV)). In approaching a claim of service connection for PTSD, the question of the existence of an event claimed as a recognizable stressor must be resolved by adjudicatory personnel. If the adjudicators conclude that the record established the existence of such a stressor(s), then and only then, should the case be referred for medical examination to determine the sufficiency of the stressor and as to whether the remaining elements required to support the diagnosis of PTSD have been met. In such a referral, the adjudicators should specify to the examiner(s) precisely what stressor or stressors has been accepted as established by the record, and the medical examiners must be instructed that only those events may be considered in determining whether the appellant was exposed to a stressor and what the nature of the stressor or stressors was to which the appellant was exposed. In other words, if the adjudicators determine that the record does not establish the existence of an alleged stressor or stressors in service, a medical examination to determine whether PTSD due to service is present would be pointless. Likewise, if the examiners render a diagnosis of PTSD that is not clearly based on stressors in service whose existence the adjudicators have accepted, the examination would be inadequate for rating purposes. West v. Brown, 7 Vet. App. 70 (1994); Zarycki v. Brown, 6 Vet. App. 91 (1993). See also Moreau v. Brown, 9 Vet. App. 389 (1996) (neither noncombat claimant's testimony alone nor medical statements finding a relationship between claimant's recitation of claimed stressors and a diagnosis of PTSD can qualify as corroborating evidence of a stressor). As discussed below, the RO should make a specific adjudicatory determination as to whether the appellant was in combat; if not, ask him to provide any further specific information as to his alleged stressors; utilize the assistance of the U.S. Armed Services Center for Research of Unit Records (USASCRUR); make a specific determination as to which stressor(s) are verified; and, only if a stressor has been verified, have the appellant examined by a VA psychiatrist to assess whether there is any link between any diagnosis of PTSD and any verified stressor. With regard to the claim of entitlement to an evaluation in excess of 10 percent for dermatitis, the appellant testified at a November 1998 hearing that he had received treatment, and was presently receiving treatment, at a medical facility associated with Nellis Air Force Base (AFB). (See Transcript at p. 5.) The record includes some documentation from the Nellis Federal Hospital concerning treatment of PTSD, but there does not appear to be any records concerning treatment of dermatitis. In order to ensure that all pertinent evidence is available for appellate review, this claim will be remanded so that these records may be associated with the record. In addition, the appellant should be afforded a VA dermatology examination to determine the nature and severity of the disability. The case is REMANDED for the following development: 1. The RO should request that the appellant supply the names and addresses of any individuals or treatment facilities that treated him for dermatitis since November 1998, and the approximate dates of such treatment. After securing any necessary releases, the RO should obtain complete clinical records of such treatment and associate them with the claims file. 2. After securing any necessary release, the RO should contact the medical facilities at Nellis AFB and ask for copies of all treatment records, regardless of date or subject, concerning the appellant. All documents thus obtained should be associated with the claims file. 3. The RO should request the appellant to supply names and addresses of any individuals or facilities that treated him for PTSD since November 1998, and the dates of such treatment. After securing any needed releases, the RO should obtain complete clinical records of such treatment and add them to the claims file. 4. The RO must determine whether the appellant, based on the evidence of record, engaged in combat. If so, absent evidence to the contrary, that conclusion must be accepted as conclusive evidence of the claimed in-service stressor. The RO's attention is directed to the law cited above and to a recent VA General Counsel opinion. VA O.G.C. Prec. Op. 12- 99 (Oct. 18, 1999). 5. If the RO determines that the appellant was not engaged in combat, then he should be requested to provide, within a reasonable time, any additional information relevant to his claimed stressor(s), including specific information as to the date and location of the incident(s), full names of any casualties, the unit designation and that of any other unit involved. All information obtained should be added to the claims file. 6. On receipt of the appellant's response, or after a reasonable period of time has passed without response, the RO should review the claims file and prepare a summary of the claimed stressor(s) based on a review of all pertinent documents. This summary, and any supporting document regarding the claimed stressor(s), should be sent to USASCRUR, at 7798 Cissna Road, Suite 101, Springfield, Virginia 22150-3197. They should be asked to certify the occurrence of the incident(s) and any indication of the appellant's involvement therein. If unable to provide such information, USASCRUR should be asked to identify the agency or department that could provide such information and the RO should follow up accordingly. 7. After the above is accomplished, the RO must make a specific determination, based on the complete record, with respect to whether the appellant was exposed to a stressor or stressors in service, and if so, the nature of the specific stressor or stressors. If the RO determines that the record establishes the existence of stressor(s), the RO must specify what stressor or stressors in service it has determined the record establishes. In reaching this determination, the RO should address any credibility questions raised by the record. 8. Only if, the RO determines that the record establishes the existence of stressor(s), then the appellant should be afforded a VA psychiatric examination to determine the nature and etiology of all psychiatric disorders found present. The RO must specify for the examiner the stressor(s) that it has determined are established by the record and the examiner must be instructed that only those events may be considered for the purpose of determining whether the appellant was exposed to a stressor in service. The entire claims file and a copy of this REMAND must be made available to the examiner in conjunction with the examination, and the examination report should reflect review of pertinent material in the claims folder. If a diagnosis of PTSD is made, the examiner should specify (1) whether each alleged stressor found by the RO to be established in the record was sufficient to produce PTSD; (2) whether the remaining diagnostic criteria to support the diagnosis of PTSD have been satisfied; and (3) whether there is a link between the current symptomatology and one or more of the in-service stressors found to be established by the record by the RO and found to be sufficient to produce PTSD by the examiner. The examination report should include the rationale for all opinions expressed. All necessary special testing and evaluation should be accomplished. 9. The RO should schedule the appellant for a dermatology examination to determine the nature and severity of the service-connected dermatitis. The claims folder and a copy of this REMAND must be made available to the physician for review in conjunction with the examination. The pertinent history concerning the disability should be obtained, and all necessary tests and studies should be accomplished. The report of examination should contain a detailed account of all manifestations of the disability found to be present. The examiner should be asked to specifically comment on the presence and location of any ulceration, exfoliation, itching, crusting, lesions, disfigurement, and systemic or nervous manifestations. 10. When the above development has been completed, the RO should review the record to ensure it is in compliance with this REMAND. If not, the RO should undertake remedial action before returning the claim to the Board. See Stegall, 11 Vet. App. at 270-71. On completion of the development requested, to the extent possible, the RO should again review the record. If the benefit sought on appeal remains denied, the appellant and his representative should be furnished a supplemental statement of the case and given an opportunity to respond. The case should then be returned to the Board. He has the right to submit additional evidence/argument on the matters the Board has remanded to the RO. Kutscherousky v. West, 12 Vet. App. 369 (1999). J. F. Gough Member, Board of Veterans' Appeals