Citation Nr: 1119713 Decision Date: 05/23/11 Archive Date: 06/06/11 DOCKET NO. 07-34 520A ) DATE ) ) On appeal from the Department of Veterans Affairs Medical and Regional Office Center in Wichita, Kansas THE ISSUE Entitlement to service connection for gout, to include as secondary to service-connected hypertension. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Scott Shoreman, Associate Counsel INTRODUCTION The Veteran had active service in the Navy from April 1975 to July 1997. This matter comes before the Board of Veterans' Appeals (Board) from a July 2006 rating decision of the above Department of Veterans Affairs (VA) Regional Office (RO). The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if further action is required. REMAND The post-service VA treatment records indicate that in November 2003 the Veteran was diagnosed with acute gout. P.H.J., M.D., a private physician, wrote in February 2004 that the Veteran had a history of gout in his foot and had been treated with steroid injections by VA. February 2005 VA treatment records indicate that he had swelling and pain in his left ankle that had begun two days before and became worse overnight. His uric acid was mildly elevated, and he was given toradol and solumedrol for acute gout and was to take a medrol dose pack and switch from ibuprofen to indocin during acute episodes. August 2005 VA testing indicated that the Veteran's uric acid level was 10.7, and in March 2006 VA it was 7.6. The Veteran has been awarded service connection for hypertension. In his April 2006 claim, he wrote that he had developed gout in his great right toe while taking hydrochlorothiazide. He had continued to have exacerbations of the gout, usually in his left foot and more recently in his left ankle. He had been switched from hydrochlorothiazide to lisinopril, but noted that gout can be a side effect of lisinopril. He submitted general medical information indicating that high blood pressure can be a risk factor for gouty arthritis and that gout is a side effect of lisinopril. In McClendon v. Nicholson, 20 Vet. App. 79 (2006), the Court of Appeals for Veterans Claims reviewed the criteria for determining when a VA examination is required by applicable regulation, and how the Board applies 38 C.F.R. § 3.159(c) (2010). The three salient benchmarks are: competent evidence of a current disability or recurrent symptoms; establishment of an in-service event, injury, or disease; and indication that the current disability may be associated with an in-service event. Although there is no in-service event, injury, or disease related to gout, the Board believes that the medical information which the Veteran submitted regarding the connection between gout and hypertension necessitates a VA examination to secure competent medical evidence as to the relative likelihood that his gout is secondary to the service-connected hypertension. Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a VA examination to determine the nature and etiology of his gout. The claims folder must be made available to the examiner for review in connection with the examination. All appropriate tests and studies and/or consultation(s) should be accomplished. a. The examiner should specifically state whether it is at least as likely as not (i.e., to at least a 50-50 degree of probability) that the Veteran has gout which is causally or etiologically related to his active Navy service, to include whether it is causally related to or has been aggravated by his service-connected hypertension; OR whether such a causal or etiological relationship is unlikely (i.e., less than a 50-50 probability). b. If gout was first manifested after service with no direct relationship thereto, but was later aggravated by the hypertension, the examiner should describe the pre-existing baseline manifestations of gout which existed before the aggravation occurred, and identify the increased symptoms of gout which, in the expert's opinion, are proximately due to the service-connected hypertension. c. Note: As used above, the term "at least as likely as not" does not mean merely within the realm of medical possibility, but rather that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of causation as it is to find against it. d. Note: The term "aggravated" in the above context refers to a permanent worsening of the underlying condition, as contrasted to temporary or intermittent flare-ups of symptomatology which resolve with return to the baseline level of disability, and also does not include an increase in the disorder which is due to the natural progress of the condition. e. If the reviewer cannot answer any question in the case without resorting to speculation, the reviewer should so state, and explain why that is so. 2. Then readjudicate the Veteran's claim of service connection for gout, to include as secondary to the service-connected hypertension. If any benefits sought on appeal remain denied, the Veteran and his representative should be provided with a Supplemental Statement of the Case. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2002 & Supp. 2010). ___________________________ ANDREW J. MULLEN Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a final decision of the Board of Veterans' Appeals is appealable to the U.S. Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a final decision of the Board on the merits of the appeal. 38 C.F.R. § 20.1100(b) (2010).