Citation Nr: 0006636 Decision Date: 03/13/00 Archive Date: 03/17/00 DOCKET NO. 95-18 221 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to an increased (compensable) rating for bilateral hearing loss. 2. Entitlement to service connection for peripheral neuropathy. 3. Entitlement to service connection for growths on the neck and head. 4. Entitlement to service connection for post-traumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD K. R. McCormack, Associate Counsel INTRODUCTION The veteran had active military service from December 1966 to November 1968. This matter comes to the Board of Veterans' Appeals (Board) from a Department of Veterans Affairs (VA) Houston Regional Office (RO) November 1994 rating decision which denied a compensable evaluation for bilateral hearing loss, and denied service connection for peripheral neuropathy, growths on his neck and head and PTSD. The claim of service connection for PTSD will be held in abeyance pending completion of the development requested below in the remand portion of this decision. FINDINGS OF FACT 1. The veteran has level II hearing in both ears. 2. He performed active service in the Republic of Vietnam during the Vietnam era. 3. No competent medical evidence has been presented to show that the veteran's peripheral neuropathy was evident in service or became manifest to a compensable degree within one year of his last exposure to Agent Orange. 4. Competent medical evidence has not been presented to establish a link between veteran's peripheral neuropathy and his period of service. 5. No competent medical evidence has been presented to establish a link or nexus between the growths on the veteran's neck and head and his period of service. 6. The claim of service connection for PTSD is plausible. CONCLUSIONS OF LAW 1. The criteria for a compensable evaluation for bilateral hearing loss have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.85, 4.86, Diagnostic Code 6100 (1999). 2. The veteran has not submitted a well-grounded claim of entitlement to service connection for peripheral neuropathy. 38 U.S.C.A. § 5107 (West 1991). 3. The veteran has not submitted a well-grounded claim of entitlement to service connection for growths on the neck and head. 38 U.S.C.A. § 5107 (West 1991). 4. The claim for service connection for PTSD is well grounded. 38 U.S.C.A. § 5107(a) (West 1991). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Bilateral Hearing Loss The veteran contends that his bilateral hearing loss is more disabling than the noncompensable evaluation reflects, thereby warranting an increased evaluation. As a preliminary matter, the Board finds that the veteran's claim for an increased evaluation for his service-connected bilateral hearing loss is well grounded pursuant to 38 U.S.C.A. § 5107(a) as it is plausible or capable of substantiation. Murphy v. Derwinski, 1 Vet. App. 78 (1990). In general, an allegation of an increased disability is sufficient to establish a well-grounded claim seeking an increased rating. Proscelle v. Derwinski, 2 Vet. App. 629 (1992). Here, the veteran's contention concerning the severity of his bilateral hearing loss (within the competence of a lay party to report) is sufficient to conclude that this claim is well grounded. The Board finds that the facts relevant to this issue have been properly developed and that the obligation of VA to assist the veteran has been satisfied. Disability evaluations are determined by the application of the VA Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. Part 4 (1999). Separate diagnostic codes identify the various disabilities. When evaluating a disability, any reasonable doubt regarding the degree of disability is resolved in favor of the claimant. 38 C.F.R. § 4.3 (1999). If there is a question as to which of two evaluations should apply, the higher rating is assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is assigned. 38 C.F.R. § 4.7 (1999). Where entitlement to VA compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a review of the recorded history of a disability is necessary in order to make an accurate evaluation, see 38 C.F.R. §§ 4.41, 4.42 (1998), the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). Evaluations of bilateral hearing loss range from noncompensable to 100 percent based on organic impairment of hearing acuity as measured by the results of controlled speech discrimination tests together with the average hearing threshold level as measured by pure tone audiometry tests in the frequencies of 1,000, 2,000, 3,000 and 4,000 Hertz. Audiometric test results can be translated into a numeric designation ranging from level I to level XI to evaluate the degree of disability from hearing loss. The degree of disability is determined by application of a rating schedule that establishes eleven auditory acuity levels, ranging from Level I (for essentially normal acuity) through Level XI (for profound deafness). 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.85, 4.86, 4.87, Diagnostic Codes 6100 through 6110 (1999). The assignment of disability ratings in hearing cases is derived by a mechanical application of the Rating Schedule to the numeric designation assigned after audiometric evaluations are rendered. Lendenmann v. Principi, 3 Vet. App. 345 (1992). The evaluations derived from the Schedule are intended to make proper allowance for improvement by hearing aids. 38 C.F.R. § 4.86. The Board notes that, effective June 10, 1999 (during the pendency of this appeal), the VA's schedule for rating disabilities, 38 C.F.R. Part 4, was amended with regard to rating hearing impairments and other diseases of the ear. 64 Fed. Reg. 25,208 (codified at 38 C.F.R. § 4.85-4.87). Because the veteran's claim was filed before the regulatory change occurred, he is entitled to application of the version most favorable to him. Karnas v. Derwinski, 1 Vet. App. 308, 311 (1991). In the instant case, it does not appear that the RO provided the veteran notice of the revised regulations in the supplemental statement of the case issued in September 1999. However, the Board finds that the change in the regulation has had no effect on the outcome of the veteran's claim. Thus, while the veteran may not have been notified about the revised regulations, the Board finds that it may proceed with this decision on the merits with consideration of the original and revised regulations, without prejudice to the veteran. See Bernard v Brown, 4 Vet. App. 384, 393-394 (1993). VA outpatient treatment records, dated from May 1993 to August 1996, show that the veteran was afforded audiological examination in July 1993. At that time, his auditory thresholds at 1,000, 2,000, 3,000 and 4,000 Hertz were 15, 15, 30 and 45 decibels, respectively, averaging 26 decibels in the right ear, and 15, 25, 50 and 55 decibels, respectively, averaging 36 decibels in the left ear. Speech discrimination was 96 percent correct in the right ear and 94 percent correct in the left ear. This equates to level I hearing in each ear and corresponds to a noncompensable disability rating. By April 1994 letter, a Readjustment Counseling Therapist with Laredo Vet Center indicated that the veteran had a hearing loss warranting a 10 percent rating. On VA ear examination in May 1994, the veteran was diagnosed a having severe, bilateral hearing loss. On VA audiological examination in May 1994, his auditory thresholds at 1,000, 2,000, 3,000 and 4,000 Hertz were 10, 15, 30 and 45 decibels, respectively, averaging 25 decibels in the right ear, and 10, 25, 50 and 50 decibels, respectively, averaging 34 decibels in the left ear. Speech discrimination was 96 percent correct, bilaterally. This equates to level I hearing in both ears. On VA examination in July 1999, the veteran was diagnosed as having bilateral hearing loss. On VA audiological examination in July 1999, the auditory thresholds at 1,000, 2,000, 3,000 and 4,000 Hertz were 15, 20, 50 and 55 decibels, respectively, averaging 35 decibels in the right ear, and 10, 50, 50 and 60 decibels, respectively, averaging 43 decibels in the left ear. Speech discrimination was 90 percent correct, bilaterally. This equates to level II hearing in each ear and corresponds to a noncompensable disability rating. The most current medical evidence demonstrates that a compensable disability rating is not warranted for the veteran's bilateral hearing loss. The most recent average pure tone threshold readings along with the speech recognition testing scores demonstrate that he has no worse than level II hearing in the right ear and level II hearing in the left ear. This corresponds to a noncompensable disability rating. As such, the schedular criteria for a compensable evaluation for bilateral hearing loss are not met under 38 C.F.R. § 4.85, Diagnostic Code 6100. While the Board does not minimize the difficulty the veteran may be encountering as a result of his service-connected bilateral hearing loss, his current hearing loss is not shown to be of sufficient severity to warrant the assignment of a compensable evaluation. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. § 4.85, Diagnostic Code 6100. The Board has also considered all other potentially applicable provisions of 38 C.F.R. Parts 3 and 4, whether or not they have been raised by the veteran, as required by Schafrath v. Derwinski, 1 Vet. App. 589 (1991), but no section provides a basis on which to assign a compensable disability evaluation. The evidence is not so evenly balanced that there is doubt as to any material issue. 38 U.S.C.A. § 5107. II. Peripheral Neuropathy and Growths on the Neck and Head The veteran contends that his peripheral neuropathy and the growths on his neck and head result from exposure to Agent Orange during his active service in Vietnam. Thus, he maintains that service connection is warranted for peripheral neuropathy and growths on the neck and head. Before reaching the merits of the veteran's claims, the threshold question to be resolved is whether he has presented evidence that his claims of service connection are well grounded. See 38 U.S.C.A. § 5107(a) (West 1991). A well- grounded claim is a plausible claim that is meritorious on its own or capable of substantiation. See Murphy, 1 Vet. App. at 78. An allegation alone is not sufficient; the appellant must submit evidence in support of his claim that would "justify a belief by a fair and impartial individual that the claim is plausible." 38 U.S.C.A. § 5107(a) (West 1991); Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992). In order for a claim to be well grounded, there must be competent evidence of current disability (a medical diagnosis); of incurrence or aggravation of a disease or injury in service (lay or medical evidence); and of a nexus between the inservice disease or injury and the current disability (medical evidence). Caluza v. Brown, 7 Vet. App. 498 (1995). Service connection may be granted for disability resulting from chronic disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110; (West 1991 & Supp. 1999); 38 C.F.R. § 3.303 (1999). Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (1999). For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." Continuity of symptomatology is required where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b) (1999). A veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the Vietnam era, shall be presumed to have been exposed during such service to an herbicide agent (Agent Orange), unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. 38 C.F.R. § 3.307(a)(6)(iii) (1999). If a veteran was 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) (1999) are met, even if there is no record of such disease during service: chloracne or other acneform diseases consistent with chloracne, Hodgkin's disease, multiple myeloma, non-Hodgkin's lymphoma, acute and subacute peripheral neuropathy, porphyria cutanea tarda, prostate cancer, respiratory cancers, and soft-tissue sarcomas. 38 U.S.C.A. § 1116 (West 1991 & Supp. 1999); 38 C.F.R. § 3.309(e) (1999). Chloracne, or other acneform disease, as well as acute and subacute peripheral neuropathy may be presumed to have been incurred during active military service as a result of exposure to Agent Orange if it is manifest to a degree of 10 percent within the first year after the last date on which the veteran was exposed to Agent Orange during active service. 38 C.F.R. § 3.307(a)(6)(ii) (1999). The veteran's service personnel records reflect that he served on active duty in Vietnam from December 1967 to November 1968. A review of his service medical records reveals that clinical evaluation of his extremities, neurologic system, neck, head and skin revealed normal findings at the time of his December 1966 service entrance medical examination. His March 1969 service separation examination also shows that clinical evaluation of his extremities, neurologic system, neck, head and skin were normal. In the accompanying Report of Medical History, the veteran indicated that he had not had any skin diseases, tumors, growths or cysts. On VA medical examination in March 1974, a neurological evaluation of the veteran revealed normal findings. Clinical evaluation of his skin, neck and head also revealed normal findings. VA outpatient treatment records, dated from May 1993 to August 1996, show that the veteran was diagnosed as having peripheral neuropathy on occasion. March 1994 VA electromyograph (EMG) and nerve conduction studies (NCS) show that the veteran was assessed as having bilateral moderate sensory carpal tunnel syndrome without evidence of denervation. On VA neurological examination in May 1994, the veteran was diagnosed as having bilateral carpal tunnel syndrome which was treated with wrist splints. It was noted that he had possible peripheral neuropathy, affecting his arms and legs and of an uncertain etiology. On VA ear disease examination in May 1994, the veteran was diagnosed a having dermatomycosis of his neck and scalp. A January 1997 EMG and NCS report from Laredo Vet Center shows that the veteran was assessed as having right sensory carpal tunnel syndrome. It was noted that he also appeared to have carpal tunnel syndrome on the left, even though the sensory studies were normal. On the basis of the foregoing evidence, the Board is of the opinion that the veteran has not presented evidence of well- grounded claims of service connection for peripheral neuropathy due to Agent Orange exposure and growths on the neck and head due to Agent Orange exposure. In particular, while it is undisputed that he served in Vietnam, his service medical records are totally devoid of any report or clinical finding of peripheral neuropathy or growths on his head or neck. In addition, the post-service medical evidence does not show that his peripheral neuropathy was manifested to a compensable degree within one year following his last exposure to Agent Orange. Rather, the VA outpatient treatment records show that the first diagnosis of peripheral neuropathy was rendered no earlier than May 1993, more than 24 years following his last exposure to Agent Orange. For these reasons, the veteran's peripheral neuropathy may not be presumed to have been incurred during his period of service, as the requirements set forth in 38 C.F.R. §§ 3.307, 3.309 (1999) have not been met. The Board also observes that the growths on the veteran's neck and head have been attributed to dermatomycosis (a superficial, fungal skin infection). As such, he has not submitted evidence of a current diagnosis of a disease for which service connection may be presumed due to an association with exposure to herbicide agents. See 38 C.F.R. § 3.307, 3.309. Nevertheless, the veteran may still be entitled to service connection on a direct basis if it can be shown that his peripheral neuropathy and growths on his neck and head had their onset during his military service. See Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994); Brock v. Brown, 10 Vet. App. 155 (1997). With this in mind, the Board also finds that the veteran has not submitted competent medical evidence that his peripheral neuropathy and growths on his neck and head are medically related to his period of service. As reported earlier, his service medical records do not show any report or clinical finding of peripheral neuropathy or growths on his head or neck. In addition, while post-service VA medical records show that he was diagnosed as having peripheral neuropathy and growths on his neck and head, such diagnoses were rendered more than two decades after his separation from service. Moreover, none of the postservice medical records establish any causal link or nexus between his peripheral neuropathy and his period of service or the growths on his neck and head and his period of service. Thus, the medical evidence of record does not demonstrate a causal link or nexus between the veteran's peripheral neuropathy and his period of service or the growths on his neck and head and his period of service. While the Board is sympathetic to the beliefs of the veteran, his claims of service connection for peripheral neuropathy and growths on the neck and head cannot be viewed as well grounded under such circumstances. Caluza, 7 Vet. App. at 506. The Board has carefully considered the veteran's contentions regarding the etiology of his peripheral neuropathy and the growths on his neck and head. However, as a layman, he is not qualified to render such opinions as to medical diagnoses, etiology or causation. Espiritu v. Derwinski, 2 Vet. App. 492 (1992). The Board notes that copies of VA Agent Orange Briefs and the April 1998 Agent Orange Review were received from the U.S. Armed Services Center for Research of Unit Records (USASCRUR) in July 1998. However, as this evidence does not specifically relate the onset of the veteran's peripheral neuropathy and growths on his neck or head to his period of active service, or exposure to Agent Orange therein, it cannot itself satisfy the nexus element which would well ground these claims. Sacks v. West, 11 Vet. App. 314 (1998). In denying the veteran's claims, the Board has considered the matter of resolution of the benefit of the doubt. However, the benefit-of-the-doubt rule only applies when a claim is well grounded. Epps v. Gober, 126 F.3d 1464 (Fed. Cir. 1997). Such is not the case here where, as reported earlier, the veteran's claims of service connection for peripheral neuropathy and growths on the neck and head are not well grounded on either a direct or presumptive basis. ORDER A compensable evaluation for bilateral hearing loss is denied. Service connection for peripheral neuropathy is denied. Service connection for growths on the neck and head is denied. REMAND A claim of service connection for PTSD is well grounded when the veteran submits medical evidence of a current disability, lay evidence (presumed credible for these purposes) of in- service stressor, and medical evidence of a nexus between service and the current disability. Gaines v. West, 11 Vet. App. 353, 357 (1998). In this case, the record includes VA medical records, showing diagnoses of PTSD, thereby satisfying the first element of a well-grounded claim. The veteran has also told VA examiners that his PTSD was the result of his exposure to combat during his active duty service in Vietnam. The Board observes that the truthfulness of this evidence must be presumed when determining whether a claim is well grounded. King v. Brown, 5 Vet. App. 19, 21 (1993). This evidence satisfies the second element of a well-grounded claim of service connection for PTSD. As to the third element of a well-grounded claim, competent medical evidence of a link or nexus between service and the current disability, an April 1994 letter from a counseling therapist with Laredo Vet Center indicated that the veteran's PTSD was manifested by recollection of his traumatic experiences in Vietnam. While not conclusive, this finding parallels the veteran's assertions of a relationship between in-service stressors and current PTSD symptoms, thereby constituting competent medical evidence linking the post- service symptoms to his period of service. See Gaines, 11 Vet. App. at 357; Caluza, 7 Vet. App. at 506. Therefore, this claim is well grounded as the record includes medical evidence of current disability, presumptively truthful lay evidence of an in-service stressor, and medical evidence of a nexus between service and the current disability. Gaines, 11 Vet. App. at 357. Because this claim is well grounded, VA has a statutory obligation to assist the veteran in the development of facts pertinent to this claim. 38 U.S.C.A. § 5107(a). Service connection for PTSD requires 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 inservice stressor; and credible supporting evidence that the claimed inservice stressor occurred. 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 inservice stressor. 38 C.F.R. § 3.304(f) (1999). Prior to June 18, 1999, service connection for PTSD required medical evidence establishing a clear diagnosis of the condition, credible supporting evidence that the claimed inservice stressor actually occurred, and a link, established by medical evidence, between current symptomatology and the claimed inservice stressor; if the claimed stressor was related to combat, service department evidence that the veteran engaged in combat or that he was awarded a combat citation was accepted in the absence of evidence to the contrary, as conclusive evidence of the claimed in-service stressor. 38 C.F.R. § 3.304(f) (1999). 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 veteran was exposed to a stressor and what the nature of the stressor or stressors was to which the veteran 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). The veteran's service records show that he served in Vietnam from December 1967 to November 1968 as a cannoneer with Battery A, 2nd. Battalion, 319th Artillery, 101st. Air Cavalry Division. He reportedly participated in three campaigns, including the Tet counter-offensive. His military awards include the parachute badge, Vietnam Campaign Medal with "1960" device and Bronze Star Medal. The veteran's service medical records do not show that he was treated for any psychiatric disability. Nevertheless, as reported earlier, the record includes VA medical records which show that he has been diagnosed as having PTSD subsequent to his separation from service. By May 1994 statement in support of the claim, the veteran described incidents which he claimed served as the requisite combat stressors for his claim of service connection for PTSD. He specifically reported that he saw combat during the Tet Offensive in January 1968 and during 40 days of fighting in Phuoc Vinh. He also reported that his sergeant was killed when a mortar hit his artillery position. He listed the names of three men who were involved in this combat. In July 1998, an official with the USASCRUR provided a copy of the 1967 and 1968 unit history of the 2nd. Battalion (Airborne) 319th Artillery, and a copy of an operational report for the 3rd. Brigade, 101st. Air Cavalry Division, were associated with the claims folder. The 1967 and 1968 unit history of the 2nd. Battalion, 319th Artillery shows that it fired over 1,300 missions, expending over 15,000 rounds in support of ground operations in January 1968. In February 1968, it provided direct support to the 3rd Brigade, 101st Air Cavalry Division during the Tet Offensive. By July 1998 letter, an official with the USASCRUR reported that, in order to provide further research concerning casualties, additional information about casualties would have to be received from the veteran. He also reported that such information included the most specific date possible, type and location of the incidents, numbers and full names of the casualties and unit designations to the company level. He indicated that USASCRUR did not maintain morning reports for the 2nd. Battalion, 319th Artillery from 1967 or 1968. He indicated that such records could be obtained from the National Personnel Records Center (NPRC). In this case, a review of the claims folder does not show that the RO has contacted the veteran about providing USASCRUR with additional information about casualties. Such development is necessary for a fully informed evaluation of this claim. The Board must consider independent medical evidence in supporting recorded findings, rather than providing its own medical judgment in the guise of a Board opinion. Where the Board determines that the evidence of record is insufficient for a fully informed evaluation, the Board is free to supplement to the record by seeking advisory opinion or ordering a medical examination. Colvin v. Derwinski, 1 Vet. App. 175, 175 (1991). In this case, the veteran's combat stressors have not been verified. Thus, although the record includes VA medical records which show that he was diagnosed as having chronic PTSD, the stressors relied on in rendering the diagnoses were not verified. Moreover, to complicate matters further, on most recent VA psychiatric examination, no psychiatric diagnosis was identified. Thus, another VA psychiatric examination is necessary for a fully informed evaluation of this claim. Colvin, 1 Vet. App. at 175. In light of the foregoing, the case is REMANDED for the following action: 1. The RO should contact the veteran and request that he identify the names, addresses, and approximate dates of treatment of all medical care providers who may have treated him for PTSD since his separation from service. After obtaining the necessary releases, the RO should attempt to obtain copies of all pertinent treatment records identified (not already of record). 2. The RO should also request from the veteran a statement containing as much detail as possible regarding any casualties to which he was exposed in combat during service. He should be asked to provide specific details of the casualties, such as dates, type and location of the casualties, numbers and full names of the casualties, unit designations to the company level and any other identifying information concerning casualties. He should be told that the information is needed to obtain supportive evidence of the stressful events and that failure to respond may result in adverse action. 3. The RO should contact the NPRC through official channels and request that it forward copies of any morning reports and additional service medical records pertaining to in-service treatment afforded the veteran. 4. Thereafter, the RO should review the claims folder and prepare a summary including all associated documents and then make a specific determination, in accordance with the provisions of 38 C.F.R. § 3.304(f), with respect to whether the veteran was exposed to a stressor, or stressors, in service, and, if so, what was the nature of the specific stressor or stressors established by the record. 5. Only if the RO determines that the veteran was exposed to a stressor or stressors during service, he should be afforded a VA psychiatric examination to determine the correct diagnosis of any psychiatric disorder found to be present. All necessary testing and evaluation should be accomplished and the claims folder must be made available to the examiner for review in conjunction with the examination. The examination report should reflect a review of pertinent material in the claims folder and the examiner should be requested to integrate previous psychiatric findings and diagnoses with current findings. The RO should inform the examiner of the stressor, or stressors, that have been verified. If a diagnosis of PTSD is deemed appropriate, the examiner should specify (1) the factors relied on to support the diagnosis; (2) the specific stressor, or stressors, that prompted the diagnosis; and (3) whether there is a link between the current symptoms and one or more of the inservice stressors. The examiner should specifically state whether a diagnosis of PTSD is supportable solely by the stressor, or stressors, that have been verified. The report of examination should include the complete rationale for all opinions expressed. 6. After completing any further actions deemed necessary, the RO should then readjudicate the claim of service connection for PTSD. 7. Following completion of the foregoing, the RO must review the claims folder and ensure that all of the above foregoing development has been accomplished. If any development is incomplete, appropriate remedial action should be implemented. Stegall v. West, 11 Vet. App. 268 (1998). The veteran has the right to submit additional evidence and argument on the matter remanded to the RO. Kutscherousky v. West, 12 Vet. App. 369 (1999). J. F. Gough Member, Board of Veterans' Appeals