Citation Nr: 1006399 Decision Date: 02/22/10 Archive Date: 03/02/10 DOCKET NO. 08-04 785 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to service connection for benign prostrate hypertrophy (BPH). 2. Entitlement to service connection for coronary artery disease (CAD), including as secondary to service-connected diabetes mellitus, Type II (DM). REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD Nicole Klassen, Associate Counsel INTRODUCTION The Veteran served on active duty from December 1967 to July 1969. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a February 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia, which denied the above claims. 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 Unfortunately, a remand is required in this case. Although the Board sincerely regrets the additional delay, it is necessary to ensure that there is a complete record upon which to decide the Veteran's claim so that he is afforded every possible consideration. In regard to his BPH, the Veteran contends that this condition is causally related to prostate infections he had during military service. Specifically, the Veteran reports that he was treated for painful urination during service, and received VA treatment for the same symptomatology in the months directly following separation from service. He has also reported a continuity of symptomatology since separation from service. Service treatment records reveal that the Veteran was treated for painful urination with some greenish urethral discharge in May 1969, which was diagnosed as non-specific urethritis and was treated with antibiotics. Additionally, in June 1969, he again sought treatment for pain on urination with a greenish milky discharge. The doctor noted that his previous condition had been cleared up with antibiotics, and as such, prescribed him with another round of the same antibiotic. Finally, at his July 1969 separation examination, the Veteran reported a history of frequent or painful urination. Eight days after separation from service, the Veteran sought VA treatment for burning pain on urination, which was again treated with antibiotics. The Veteran received follow-up treatment on several occasions from August 1969 to October 1969, during which time he provided urine samples. After completing the antibiotics, the Veteran's urine was noted to be negative and no further diagnosis was provided. A review of the record indicates that the Veteran received private treatment for a prostate condition from Dr. Harry Voles from 1970 to 1979, and from Dr. Jack Amie from 1981 to 1983; however, because such treatment was many years earlier, and because Dr. Voles is now deceased, these records are no longer available. In July 2005, the Veteran was afforded a VA genitourinary examination. At the outset of the examination report, the examiner noted that the Veteran's claims file was not available for review. The Veteran reported that he had been treated for prostate problems on several occasions during service. He also reported that his symptoms had worsened during the 1980s, when he had trouble with dysuria, burning, and fullness; he indicated that these symptoms were treated with antibiotics. Finally, he reported that, more recently, his symptoms have included dysuria and nocturia. On examination, the examiner reported that the Veteran's prostate was 1+ and smooth, with no nodules and no significant tenderness. Based on his examination, the examiner diagnosed the Veteran with BPH. The Board acknowledges that the Veteran was afforded a VA examination in July 2005. Significantly, however, the claims file was not available for review at the time of the examination and the examiner did not provide an opinion as to the etiology of the Veteran's BPH. As such, the examination report is not adequate for rating purposes, and this matter must be remanded. See 38 C.F.R. § 4.2 (2009) (stating that if the findings on an examination report do not contain sufficient detail, it is incumbent upon the rating board to return the report as inadequate for evaluation purposes; see also Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (stating that once VA undertakes the effort to provide an examination when developing a service-connection claim, even if not statutorily obligated to do so, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided). In regard to his CAD, the Veteran contends that this condition is causally related to his service-connected DM. In support of this contention, the Veteran asserts that he was diagnosed with CAD at the same time that he was diagnosed with DM, and as such, believes that his CAD was caused by, or is related to, his DM. In this regard, the Veteran asserts that, although he was not diagnosed with his DM until 2003, he likely had this condition at an earlier date, as conditions exist prior to the date on which they are diagnosed. The first post-service evidence of treatment for a heart condition is dated in May 2001, when the Veteran was seen by Dr. Michael H. Butler for increased dyspnea on exertion, fatigue, and occasional dizziness and edema. At that time, the Veteran reported a history of hypertension, but denied a history of DM. Dr. Butler reported that the Veteran's stress electrocardiogram (ECG) results were 1) clinically negative for angina, 2) suggestive of inferoapical ischemia with the ST segments returning to baseline quickly in recovery, 3) negative for oxygen desaturation during exercise, and 4) negative for wall motion abnormalities or ischemic dilation. In January 2003, the Veteran's private doctor, Dr. Scott Tarplee, referred him to the Diabetes Management Center (DMC) to have blood drawn. Around that same time, the Veteran was prescribed Allopurinol. Subsequently, in July 2003, the Veteran was seen by Dr. Mark T. Watkins regarding his hypertension, hyperlipidemia, and chest pain. Dr. Watkins reported that the Veteran's stress ECG results at that time were 1) clinically positive for angina, 2) clinically positive for chest pain, and 3) suggestive of inferoseptal and inferoapical ischemia, and revealed occasional isolated PVC and persistent small areas of apical anterior hypo kinesis. Based on his abnormal stress test results, several days later, the Veteran underwent a cardiac catheterization under the care of Dr. Butler, which revealed severe one vessel CAD. During follow-up treatment two weeks later, Dr. Butler reported that, based on the July 2003 cardiac catheterization results, which revealed an ejection fraction of 65 percent, the Veteran had CAD. In this regard, Dr. Butler reported that the Veteran had reported with a new onset of chest discomfort, and that a stress test had been suggestive of CAD. At that time, Dr. Butler also noted that the Veteran's other medical problems included hypertension, hypercholesterolemia, morbid obesity, and DM. In July 2003, the Veteran also sought follow-up treatment with Dr. Tarplee, who noted that the Veteran's DM, Type II, was currently well controlled. Subsequently, in March 2004, Dr. Tarplee noted that the Veteran's DM was responding well to weight loss. That same month, Dr. Tarplee submitted a statement indicating that the Veteran had DM, which either required insulin and a restricted diet, or hypoglycemic agents and a restricted diet. A review of the record reveals that the Veteran has since been undergoing regular treatment for his CAD and DM with Dr. Strickland and Dr. Tarplee. In July 2005, the Veteran was provided with a VA examination for his DM. At the outset, the cardiologist reported that the Veteran's claims file was not available for review. However, he noted the Veteran's reported history of having hypertension since 1987 or 1988, a myocardial infarction in 2003, a heart catheterization in July 2003, and another heart catheterization in May 2004, when a stent was placed. The Veteran also reported that he had been diagnosed with DM in 2003, and that he had been placed on oral medications at that time. He indicated that, following his diagnosis, he lost 40 pounds by following a strict low calorie, low sugar diet, and had been able to stop taking the oral medication in November 2004. Finally, he reported that he had since continued to seek regular follow-up treatment for his DM. Based on his examination, the examiner diagnosed the Veteran with DM, diet controlled with evidence of diabetic neuropathy in the feet, and "hypertension C.O.D.," which predated the diagnosis of DM. In an April 2008 letter, Dr. Tarplee submitted a letter indicating that the Veteran had been seen for DM and CAD since June 2003. Dr. Tarplee also provided the opinion that the Veteran's CAD most probably could be related to his hypertension and DM. Finally, in January 2009, the Veteran was provided with a VA heart examination. At the outset, the cardiologist reported that the Veteran's claims file was not available for review, but was being sent for review. However, he noted the Veteran's reported history of having chest pain in May 2003, a myocardial infarction in 2003, a cardiac catheterization in 2003, and a second cardiac catheterization in 2004 with stent placement. The doctor also noted that the Veteran was not diagnosed with DM until 2007. Based on his examination, the examiner diagnosed the Veteran with CAD and essential hypertension. He went on to provide the opinion that the Veteran's CAD was not secondary to his DM. In this regard, the examiner noted that the Veteran's CAD had begun in 2003, but that DM was not definitely diagnosed until 2007. The Board acknowledges that the Veteran was afforded a VA heart examination in January 2009. Significantly, however, the claims file was not available for review at the time of the examination, and moreover, in rendering the opinion that the Veteran's CAD was not secondary to his DM insofar as CAD was diagnosed prior to the date of onset of DM, he cited an incorrect date for the diagnosis of DM. In this regard, the Board points out that, as discussed above, the Veteran was first diagnosed with CAD in July 2003, and was first diagnosed with and treated for DM at some point between January 2003 and July 2003, not 2007. As such, because the January 2009 medical opinion is not based on an accurate factual premise, it is of little probative value. Kowalski v. Nicholson, 19 Vet.App. 171, 179 (2005) (citing Reonal v. Brown, 5 Vet. App. 458, 461 (1993) and Swann v. Brown, 5 Vet.App. 229 (1993)) (stating that the Board is not bound to accept medical opinions that are based upon an inaccurate factual background). Accordingly, a new medical examination is necessary to make a determination in this case. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (stating that once VA undertakes the effort to provide an examination when developing a service-connection claim, even if not statutorily obligated to do so, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided). Finally, the Board notes that, at his January 2009 VA heart examination, the Veteran reported that he had undergone a prostate biopsy in December 2008. Records from this biopsy, as well as any other records pertaining to treatment of his prostate should be obtained on remand. Any private treatment records pertaining to the Veteran's CAD and DM should also be obtained on remand. The Veteran should also be provided notice of the information and evidence necessary to substantiate his claim for service connection on a secondary basis. See 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2009). Accordingly, the case is REMANDED for the following action: 1. Send the Veteran a letter informing him about the information and evidence not of record (1) that is necessary to substantiate his claim for service connection for CAD on a secondary basis (see 38 C.F.R. § 3.310); (2) that VA will seek to obtain; and (3) that he is expected to provide. 2. Make arrangements to obtain a complete copy of the Veteran's treatment records from Dr. Tarplee, dated from June 2007 forward; and from Dr. Strickland, dated from January 2008 forward. 3. Ask the Veteran to identify all medical care provides that treated his prostate disorder since 1983, and make arrangements to obtain all records that he adequately identifies. The Board is particularly interested in records from a December 2008 prostate biopsy. 4. Thereafter, schedule the Veteran for a VA genitrourinary examination. The claims file and a copy of this remand must be made available to and reviewed by the examiner in conjunction with the examination. All necessary tests should be conducted. The examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any current prostate condition, including BPH, had its onset during active service or is related to any in-service disease, event, or injury. In doing so, the examiner should acknowledge the Veteran's treatment for painful urination during and directly following service, as well as his reports of a continuity of symptomatology since service. The examiner must provide a comprehensive report including complete rationales for all opinions and conclusions reached, citing the objective medical findings leading to the conclusions. 5. Schedule the Veteran for a VA heart examination. The claims file and a copy of this remand must be made available to and reviewed by the examiner in conjunction with the examination. All necessary tests should be conducted. The examiner should express an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran's CAD was either (a) caused by, or (b) aggravated by his DM. In doing so, the examiner should discuss the medical evidence of record regarding the date of onset of the Veteran's CAD and DM, as well as Dr. Tarplee's opinion that the Veteran's CAD most probably could be related to his hypertension and DM. The examiner must provide a comprehensive report including complete rationales for all opinions and conclusions reached, citing the objective medical findings leading to the conclusions. 6. Finally, readjudicate the Veteran's claims on appeal. If the claims remain denied, provide the Veteran with a supplemental statement of the case and allow an appropriate time for response. The appellant has the right to submit additional evidence and argument on the 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 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 Supp. 2009). _________________________________________________ P.M. DILORENZO Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2009).