Citation Nr: 1040974 Decision Date: 11/01/10 Archive Date: 11/12/10 DOCKET NO. 06-02 955 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUES 1. Entitlement to service connection for hypertension, to include as secondary to a service-connected disorder. 2. Entitlement to service connection for a heart disorder, claimed as coronary artery disease, to include as secondary to a service-connected disorder. 3. Entitlement to service connection for peripheral neuropathy, to include as secondary to a service-connected disorder. 4. Entitlement to service connection for an acquired psychiatric disorder, claimed as depressive disorder, to include as secondary to a service-connected disorder. 5. Entitlement to service connection for hepatitis C. 6. Entitlement to an initial evaluation greater than 20 percent for diabetes mellitus, type 2. 7. Entitlement to an initial compensable evaluation for erectile dysfunction. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD J. M. Macierowski, Counsel INTRODUCTION The Veteran served on active duty from October 1965 to October 1967. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a November 2004 rating decision by the Department of Veterans Affairs (VA) Regional Office in Chicago, Illinois (RO). The Veteran's requested hearing before the Board was held by the undersigned via videoconference with the RO; a transcript of the hearing is associated with the claims file. The Veteran's appeal was remanded by the Board in August 2007. At that time, the RO was directed to obtain VA treatment records dated from 1968 through the present. In February 2010, the VA treating facility indicated that the records from 1968 to 1974 were unavailable. With that exception, these records were requested in August 2009, and obtained in November 2009 and February 2010. Additionally, the Veteran provided additional authorization for private treatment records from Riverside Internal Medicine, which were obtained in September 2009, but did not respond to the RO's October 2009 letter requesting authorization for Rush/Presbyterian Medical Center. Thus, only those few records from Rush/Presbyterian Medical Center which were among the hard-copy VA treatment records are associated with the claims file. Accordingly, the Board finds that there has been substantial compliance with the directives of the August 2007 Remand in this case, such that an additional remand to comply with such directives is not required. See Stegall v. West, 11 Vet. App. 268 (1998). The issues of entitlement to service connection for hypertension, entitlement to service connection for a heart disorder, and entitlement to service connection for an acquired psychiatric disorder, are addressed in the Remand portion of the decision below, and are remanded to the RO via the Appeals Management Center in Washington, D.C. FINDINGS OF FACT 1. The Veteran's service treatment records show no evidence of peripheral neuropathy or hepatitis C. 2. Hepatitis C is currently diagnosed. 3. The probative and persuasive evidence of record does not relate the Veteran's hepatitis C to his military service or any incident therein. 4. The record does not contain a diagnosis of peripheral neuropathy of either lower extremity. 5. The Veteran's diabetes mellitus, type 2, is manifested by the prescription of oral hypoglycemic agents and a restricted diet, but not by medically-directed regulation of activities. 6. The evidence does not reflect diagnoses of diabetic retinopathy, diabetic nephropathy, or a skin disorder related to the Veteran's diabetes mellitus, type 2. 7. The Veteran's erectile dysfunction is manifested by loss of erectile power, but not by deformity of the penis. CONCLUSIONS OF LAW 1. Hepatitis C was not incurred in or aggravated by military service. 38 U.S.C.A. §§ 1110, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.303 (2010). 2. Peripheral neuropathy was not incurred in or aggravated by military service, and is not proximately due to, or the result of, a service-connected disorder. 38 U.S.C.A. §§ 1110, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.303, 3.310 (2010). 3. The criteria for an increased evaluation in excess of 20 percent for diabetes mellitus, type 2, have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. § 4.119, Diagnostic Code 7913 (2010). 4. The criteria for an initial compensable evaluation for erectile dysfunction have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. § 4.115b, Diagnostic Code 7522 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS After review of the claims file, the Board finds that VA has met all statutory and regulatory notice and duty to assist provisions in this case. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2010). March 2004, September 2004, and October 2007 letters satisfied the duty to notify provisions. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b) (1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The October 2007 letter notified the Veteran of regulations pertinent to the establishment of an effective date and of the disability rating. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Veteran's service treatment records and VA medical treatment records have been obtained. The Veteran indicated that he received VA outpatient treatment from 1968 to 1974, but the VA treating facility in question indicated in February 2010 that the records from that period were unavailable. Additionally, the RO asked the Veteran to provide authorization for private treatment records at Rush/Presbyterian Medical Center in an October 2009 letter, but the Veteran never provided such authorization. Otherwise, the identified private medical records have been obtained 38 U.S.C.A. § 5103A, 38 C.F.R. § 3.159. A November 2004 inquiry determined that the Veteran was not then in receipt of disability benefits from the Social Security Administration (SSA); he has not indicated that he began receiving SSA disability benefits since that time. 38 C.F.R. § 3.159 (c) (2). A VA examination was conducted in July 2004; the Veteran has not argued, and the record does not reflect, that this examination was inadequate for rating purposes. 38 C.F.R. § 3.159(c) (4); Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). There is no indication in the record that any additional evidence, relevant to the issue decided herein, is available and not part of the claims file. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of the case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Dingess/Hartman, 19 Vet. App. at 486; Shinseki v. Sanders/Simmons, 556 U.S. ____ (2009); 129 S. Ct. 1696, 2009 WL 1045952, U.S., April 21, 2009 (No. 07-1209). All the evidence in the Veteran's claims file has been thoroughly reviewed. Although an obligation to provide sufficient reasons and bases in support of an appellate decision exists, there is no need to discuss, in detail, all of the evidence submitted by the Veteran or on his or her behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that the entire record must be reviewed, but each piece of evidence does not have to be discussed). The analysis in this decision focuses on the most salient and relevant evidence, and on what the evidence shows or fails to show with respect to the appeal. The Veteran must not assume that pieces of evidence, not explicitly discussed herein, have been overlooked. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (noting that the law requires only that reasons for rejecting evidence favorable to the claimant be addressed). Service Connection Claims Service connection may be established for a disability resulting from diseases or injuries which are clearly present in service or for a disease diagnosed after discharge from service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Service connection may also be established on a secondary basis for a disability that is shown to be proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. Id.; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc) (additional disability resulting from aggravation of a nonservice-connected disorder by a service-connected disorder is also compensable under 38 C.F.R. § 3.310). After considering all information and lay and medical evidence of record in a case with respect to benefits under laws administered by the Secretary, when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt will be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. The benefit of the doubt rule is inapplicable when the evidence preponderates against the claim. Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). Hepatitis C The risk factors for hepatitis C include intravenous drug use, blood transfusions before 1992, hemodialysis, intranasal cocaine abuse, high-risk sexual activity, accidental exposure while a health care worker, and various percutaneous exposures such as tattoos, body piercing, acupuncture with non-sterile needles, shared toothbrushes, or razor blades. See Veterans Benefits Administration All Station Letter 98-110, "Infectious Hepatitis" (Nov. 30, 1998). The Veteran's service treatment records show no evidence of hepatitis C, liver dysfunction, or other related symptoms, to include at service separation. Subsequent to service, a January 1997 psychiatric outpatient treatment record noted the Veteran's report that he was recently informed that he had hepatitis C; the record noted that the Veteran believed he "probably received [hepatitis C] as a surgical nurse" at a local university hospital. A March 1997 VA liver biopsy showed changes consistent with chronic hepatitis C, but no evidence of liver cancer, autoimmune hepatitis, or alcohol-induced hepatitis. VA treatment records beginning April 1997 showed unsuccessful Interferon treatment for hepatitis C from April 1997 to September 1997, with additional attempts in 1998 and 1999. However, the probative and persuasive evidence of record does not show that the Veteran's hepatitis C is related to service. The Veteran has not asserted, and his service personnel records do not reflect, that his military service concerned a medical occupational specialty in which he would have been exposed to blood or blood products. However, the Veteran noted at a February 1996 VA outpatient visit that he had worked as a surgical technician for 24 years in the postservice period, and in a June 2008 VA outpatient treatment record, indicated that he had a possible history of high-risk sexual activity. In an January 1984 VA outpatient treatment record, the Veteran admitted a history of heroin use since 1971. In his October 2007 VA hepatitis questionnaire, he noted a history of cocaine use, which was also recorded in a December 1996 VA outpatient treatment record, as well as in several VA outpatient and inpatient substance abuse program treatment records dated through 2010. Thus, all of the risk factors endorsed by the Veteran were documented to have occurred after his service separation. Moreover, there are no objective medical opinions of record relating his hepatitis C to his military service. The Veteran's statements as to the relationship between his hepatitis C and his military service have been considered, but the Board finds that they are not probative, as the Veteran lacks the medical training necessary for such an opinion as to the etiology of his hepatitis C to be an informed one. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (holding that threshold considerations as to the probative value of a medical opinion are whether the person opining is suitably qualified and sufficiently informed); 38 C.F.R. § 3.159(a) (1). Because the probative and persuasive evidence of record does not relate his hepatitis C to his military service, the preponderance of the evidence is against the Veteran's claim for service connection. As such, the benefit of the doubt doctrine is inapplicable, and the claim must be denied. See 38 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Peripheral Neuropathy In a claim for service connection, the ultimate credibility or weight to be accorded evidence must be determined as a question of fact. The Board determines whether (1) the weight of the evidence supports the claim, or (2) the weight of the "positive" evidence in favor of the claim is in relative balance with the weight of the "negative" evidence against the claim: the appellant prevails in either event. However, if the weight of the evidence is against the appellant's claim, the claim must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. 54-56. The Veteran asserts that he has been diagnosed with peripheral neuropathy that he further asserts is related to his service- connected diabetes mellitus, type 2. Service treatment records are silent as to complaints, findings, treatment or diagnoses relating to peripheral neuropathy. The claims file has been carefully examined and, likewise, fails to disclose a diagnosis of peripheral neuropathy. At a July 1986 VA outpatient treatment visit, three weeks after he was involved in a motor vehicle accident, the Veteran stated that he had no weakness in his legs. Two July 1996 VA outpatient treatment records note that after having a stroke that month, physical examination showed absent ankle jerks, but an otherwise normal sensory and motor examination. Most critically, at the July 2004 VA diabetes mellitus examination, the Veteran denied experiencing numbness or tingling in his lower extremities, and the VA examiner found that no peripheral neuropathy existed. The Board notes that the Veteran's opinion as to medical matters, no matter how sincere, is without probative value because he, as a lay person, is not competent to establish a medical diagnosis or draw medical conclusions; such matters require medical expertise. See Grottveit v. Brown, 5 Vet. App. 91, 93 (1993); Espiritu v. Derwinski, 2 Vet. App. 492, 494-95 (1992). As noted above, a veteran seeking disability benefits must establish the existence of a disability and a connection between service and the disability. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000). Even where there is evidence of an injury or disease in service, there must be a present disability resulting from that disease or injury. See Degmetich v. Brown, 104 F.3d 1328, 1332 (Fed. Cir. 1997); Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992). In this case, the claimed disorder was not shown in service, and the preponderance of the evidence is against finding it currently exists. Accordingly, in the absence of a peripheral neuropathy diagnosis, this claim must be denied. See Rabideau, 2 Vet. App. at 143; Degmetich, 104 F.3d at 1332; see also Gilpin v. Brown, 155 F.3d 1353 (Fed. Cir. 1998). Initial Evaluation Claims Disability ratings are determined by the application of the VA's Schedule for Rating Disabilities (Schedule), which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Pertinent regulations do not require that all cases show all findings specified by the Schedule, but that findings sufficient to identify the disease and the resulting disability and above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21; see also Mauerhan v. Principi, 16 Vet. App. 436 (2002). The primary concern in a claim for an increased evaluation for service-connected disability is the present level of disability. Although the overall history of the disability is to be considered, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, when an appeal is based on the assignment of an initial rating for a disability, following an initial award of service connection for this disability, the rule articulated in Francisco does not apply. Fenderson v. West, 12 Vet. App. 119 (1999). Instead, the evaluation must be based on the overall recorded history of a disability, giving equal weight to past and present medical reports. Id. In all claims for increase, VA has a duty to consider the possibility of assigning staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). Diabetes Mellitus, Type 2 The Veteran's diabetes mellitus, type 2, is evaluated as 20 percent disabling under the provisions of 38 C.F.R. § 4.119, Diagnostic Code 7913. Under Diagnostic Code 7913, a 20 percent evaluation is warranted for diabetes mellitus requiring insulin and restricted diet or an oral hypoglycemic agent and restricted diet. 38 C.F.R. § 4.119, Diagnostic Code 7913. A 40 percent evaluation is warranted for diabetes requiring insulin, restricted diet, and regulation of activities. Id. A 60 percent evaluation is warranted for diabetes mellitus requiring insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if evaluated separately. Id. The probative and persuasive evidence of record does not support an evaluation greater than 20 percent for diabetes mellitus, type 2. The record, to include the July 2004 VA examination and a July 2009 private opinion letter, reflects that the Veteran has been instructed to follow a restricted or special diet, and is prescribed oral hypoglycemic agents. However, the record does not reflect that the Veteran requires a regulation of activities. The July 2004 VA examination noted that there was no restriction of activities, and the July 2009 private opinion letter did not identify restriction of activities as part of the Veteran's diabetes-regulation regimen. There is no other medical evidence, as required, to show such a restriction on occupational and recreational activities. Camacho v. Nicholson, 21 Vet. App. 360, 363-364 (2007) (citing 61 Fed. Reg. 20,440 (May 7, 1996)). Because the criteria are conjunctive, such that restriction of activities is required for a 40 percent (or higher) evaluation, an evaluation greater than 20 percent for diabetes mellitus, type 2, is not warranted. See also Melson v. Derwinski, 1 Vet. App. 334 (1991) (use of the conjunctive "and" in a statutory provision meant that all of the conditions listed in the provision must be met). Complications of diabetes mellitus are to be evaluated separately unless they are part of the criteria used to support a 100 percent rating. See 38 C.F.R. § 4.119, at Note. Elsewhere in this decision, determinations are made or additional development is found to be warranted with respect to other disabilities found or claimed to be related to diabetes mellitus, type 2 (peripheral neuropathy, hypertension, heart disease). Appellate consideration of the Veteran's appeal with respect to an increased initial evaluations for erectile dysfunction is made elsewhere in this decision. While noncompensable complications are considered part of the diabetic process under Diagnostic Code 7913, separate evaluations are not warranted for diabetic retinopathy, diabetic nephropathy, or a diabetic-related skin disorder, as the record does not reflect that these disorders have been diagnosed. The July 2004 VA examination found no diabetic retinopathy, symptoms of diabetic nephropathy, or diabetic skin abnormalities. Thus, the probative and persuasive evidence of record does not support additional separate compensable evaluations for diabetic complications other than those discussed elsewhere in this decision. Because the Veteran's diabetes mellitus, type 2, has not required medically-directed regulation of activities, and the record does not contain diagnoses of diabetic retinopathy, diabetic nephropathy, or a diabetic-related skin disorder, the preponderance of the evidence is against the Veteran's claim for an increased evaluation for diabetes mellitus, type 2. As such, the benefit of the doubt doctrine is inapplicable, and the claim must be denied. See 38 C.F.R. § 5107(b); Gilbert, 1 Vet. App. at 54-56. Erectile Dysfunction Service connection for erectile dysfunction, as secondary to the Veteran's diabetes mellitus, type 2, was granted by the May 2007 rating decision, and an initial noncompensable evaluation assigned under the provisions of Diagnostic Code 7522. See 38 C.F.R. § 4.115b, Diagnostic Code 7522. Diagnostic Code 7522 provides for a single 20 percent evaluation when the evidence shows deformity of the penis with loss of erectile power. Alternatively, where the Schedule does not provide a noncompensable evaluation for a diagnostic code, a noncompensable evaluation will be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31. The objective medical evidence does not show deformity of the penis associated with the Veteran's current erectile dysfunction. Although a December 1996 VA outpatient treatment record reflects that the Veteran's erectile dysfunction had its onset in August 1996, none of the private or VA outpatient treatment records, or the July 2004 VA examination report, reflect that the Veteran had both erectile dysfunction and penile deformity. The Veteran also does not contend that he has penile deformity. Consequently, the Board finds that the disability is properly evaluated as noncompensable. See 38 C.F.R. § 4.115b, Diagnostic Code 7522. The Board also observes that the Veteran has been awarded special monthly compensation under 38 C.F.R. § 3.350 for loss of use of a creative organ. Because the probative and persuasive evidence of record does not show penile deformity, the preponderance of the evidence is against the Veteran's claim for an initial compensable evaluation for erectile dysfunction. As such, the benefit of the doubt doctrine is inapplicable, and the claim must be denied. See 38 C.F.R. § 5107(b); Gilbert, 1 Vet. App. at 54-56. Extraschedular Considerations Generally, evaluating a disability using either the corresponding or analogous diagnostic codes contained in the rating schedule is sufficient. See 38 C.F.R. §§ 4.20, 4.27. However, because the ratings are averages, it follows that an assigned rating may not completely account for each individual veteran's circumstance, but nevertheless would still be adequate to address the average impairment in earning capacity caused by disability. However, in exceptional cases where the rating is inadequate, it may be appropriate to assign an extraschedular rating. 38 C.F.R. § 3.321(b). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for the service-connected disabilities in question are inadequate. Thun v. Peake, 22 Vet. App. 111, 115 (2008); see also Fisher v. Principi, 4 Vet. App. 57, 60 (1993). Therefore, initially, there must be a comparison between the level of severity and symptomatology of the Veteran's service- connected disabilities with the established criteria found in the rating schedule for that disability. Thun, 22 Vet. App. at 115. If the criteria under the rating schedule reasonably describe the Veteran's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, and the assigned schedular evaluation is adequate, and no referral is required. See VAOGCPREC 06-96, 61 Fed. Reg. 66749 (1996) (when service-connected disability affects employment "in ways not contemplated by the rating schedule[,]" § 3.321(b) (1) is applicable). With respect to the Veteran's service-connected disorders, the Board finds that the disability picture is not so unusual or exceptional in nature as to render the disability ratings inadequate. The Board finds that the criteria under which the Veteran's disabilities are rated specifically contemplate the level of his disability and symptomatology. Each of the Diagnostic Codes under which the Veteran's disabilities are rated include higher ratings which clearly require a great level of symptomatology not shown in the Veteran's case. Moreover, there are no significant manifestations of the Veteran's service- connected disabilities which are not contemplated by the rating criteria. When comparing this disability picture with the symptoms contemplated by the rating schedule, the Board finds that the Veteran's symptoms are more than adequately contemplated by the ratings for his service-connected disabilities. Moreover, there is no evidence showing that the Veteran's service-connected disabilities have caused marked interference with employment beyond that contemplated by the schedule for rating disabilities, necessitated frequent periods of hospitalization, or otherwise rendered impractical the application of the regular schedular standards utilized to evaluate the severity of his disabilities. The July 2004 VA examiner did not find that the Veteran's diabetes and related conditions impaired his ability to perform his physical employment. The assigned ratings reflect mild to moderate impairment in relative respect to the maximum available schedular evaluation under each Diagnostic Code. Therefore, the currently assigned ratings for the Veteran's disabilities more than reasonably describe his disability level and symptomatology. Therefore, the currently assigned schedular evaluations are adequate, and the Board finds that the Veteran's disability picture cannot be characterized as an exceptional case with respect to any of the issues on appeal, so as to render the schedular evaluations inadequate. The threshold determination for a referral for extraschedular consideration has not been met, and consequently, the Board concludes that the Veteran is not entitled to referral for an extraschedular rating. See VAOGCPREC 06-96, 61 Fed. Reg. 66749 (1996); see also 38 C.F.R. §§ 4.115b, 4.119; Thun, 22 Vet. App. at 115. ORDER Service connection for hepatitis C is denied. Service connection for peripheral neuropathy is denied. An initial evaluation greater than 20 percent for diabetes mellitus, type 2, is denied. An initial compensable evaluation for erectile dysfunction is denied. REMAND The Veteran was first diagnosed with hypertension at a September 1980 VA outpatient visit. Angina was first noted in a 1990 VA outpatient treatment record, and a VA clinician noted in a June 2008 record that this was the first manifestation of coronary artery disease. Therefore, both of these disorders first manifested more than 10 years after service separation. 38 C.F.R. § 3.303. Moreover, the July 2004 VA examiner concluded that neither the Veteran's hypertension nor his coronary artery disease were due to his diabetes mellitus, type 2. The Board rejects this opinion for two reasons: it fails to provide any rationale for its conclusion, and it neglects to opine as to whether either the hypertension or the coronary artery disease, both of which had their onset prior to the Veteran being diagnosed with diabetes mellitus, were aggravated by the diabetes mellitus. See Nieves-Rodriguez, 22 Vet. App. at 304. Thus, remand is required so that a new VA opinion may be obtained. Additionally, VA outpatient treatment records beginning in May 1979, and continuing through February 2010, reflect inpatient and outpatient treatment for a variety of acquired psychiatric disorders (PTSD, depressive disorder, major depression, and anxiety), as well as for a variety of substance abuse issues (cocaine, heroin, marijuana, and alcohol dependency). A VA examination was conducted in July 2004; the examiner found that while the Veteran did not meet the diagnostic criteria for PTSD, he did meet the criteria for depressive disorder. However, no opinion as to etiology was offered, and the remaining evidence of record is insufficient on which to base an appellate decision. The record contains some indication that the Veteran may have PTSD as a result of events he witnessed during his in-country Vietnam service; a July 1996 VA PTSD clinic record notes that the Veteran's PTSD questionnaire results indicate present of PTSD symptoms related to Vietnam combat, and an August 2009 VA outpatient treatment record documented the Veteran's stressors as well as his indication that he self-medicated his symptoms with drugs and alcohol. Especially because the July 2004 VA examination is inadequate, a new VA examination must be conducted to reconcile the Veteran's various psychiatric diagnoses, and to determine their etiology. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (holding that if VA provides the Veteran with an examination in a service connection claim, the examination must be adequate). Accordingly, the issues of entitlement to service connection for hypertension, entitlement to service connection for a heart disorder, and entitlement to service connection for an acquired psychiatric disorder, are remanded for the following action: 1. Forward the Veteran's claims file to an appropriate VA examiner to determine whether his hypertension and/or heart disorder have been aggravated by a service-connected disorder, to include his service-connected diabetes mellitus. The Veteran need not be scheduled for examination unless such examination is determined to be necessary by the examiner. After review of the Veteran's claims file, the examiner should opine as to whether it is at least as likely as not (50 percent probability or more) that any current hypertension or heart disorder is medically related to, or aggravated by, any service-connected disability, particularly diabetes mellitus, type 2. If the examiner finds that the Veteran's hypertension or heart disorder is aggravated by a service- connected disability, the examiner should indicate the degree of disability of the hypertensive disorder or heart disorder before it was aggravated and the current degree of disability of hypertensive disorder or heart disorder. The examiner should provide a complete rationale for all conclusions, and be aware that aggravation of a disability requires that the disability underwent a permanent increase of the severity of the underlying pathology of the condition, as opposed to a temporary exacerbation or intermittent flare-up of the associated symptoms. Hunt v. Derwinski, 1 Vet. App. 292 (1991). 2. Schedule the Veteran for a VA examination to determine the nature and etiology of all psychiatric disorders found. The report of examination must include a detailed account of all manifestations of the psychiatric disorders found to be present. All necessary tests must be conducted and the examiner must review the results of any testing prior to completion of the report. The claims file and a copy of this Remand must be made available to the examiner in conjunction with the examination. The examiner must integrate the previous psychiatric findings and diagnoses of current findings to obtain a true picture of the nature of the Veteran's psychiatric status. If the diagnosis of PTSD is deemed appropriate, the examiner must specify whether one or more of the Veteran's claimed stressors are sufficient to cause PTSD in the Veteran. If a diagnosis or diagnoses other than PTSD is deemed appropriate, the examiner must state whether the other diagnosed disorder(s) are related to the Veteran's military service. If one or more psychiatric disorders are found to be related to service, the examiner is also asked to opine as to whether the Veteran's current alcohol and substance abuse disorders were as likely as not caused by or otherwise related to that disorder(s). A complete rationale for all opinions must be provided, citing to current clinical findings and/or claims file documents, as appropriate. The report prepared must be typed. 3. Notify the Veteran that it is his responsibility to report for the examination and to cooperate in the development of the claim. The consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2010). If the Veteran does not report for the aforementioned examination, obtain documentation showing that notice scheduling the examination was sent to the last known address of record, and indicate whether any notice that was sent was returned as undeliverable. 4. After undertaking the development above, readjudicate the Veteran's claims. If any benefit sought on appeal remains denied, provide a supplemental statement of the case to the Veteran and his representative, and an appropriate period of time in which to respond. Thereafter, return the appeal to the Board for appellate review. No action is required by the Veteran until he receives further notice; however, he may present additional evidence or argument while the case is in remand status at the RO. 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. 2010). ______________________________________________ THOMAS D. JONES Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs