Citation Nr: 1208856 Decision Date: 03/08/12 Archive Date: 03/19/12 DOCKET NO. 08-20 871 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to service connection for an acquired psychiatric condition, to include posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for hypertension, to include as secondary to a service connected disability. 3. Entitlement to service connection for cerebrovascular accident, to include as secondary to a service connected disability. REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Bridgid D. Cleary, Associate Counsel INTRODUCTION The Veteran served on active duty from March 1973 to June 1975 and from January 1991 to May 1991. This matter has come before the Board of Veterans' Appeals (Board) on appeal from a November 2004 rating decision of the St. Louis, Missouri, Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a Travel Board hearing before the undersigned Acting Veterans Law Judge in August 2011. A transcript of the hearing is associated with the claims file. 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 Social Security Administration Records The claims file contains an October 2001 Social Security Administration (SSA) decision; however, the file does not include evidence that the Veteran's SSA records were sought. Although the Veteran's SSA claim was ultimately unsuccessful, this decision relates directly to the disabilities now claimed before VA. As such, records relating to this SSA decision are likely to give rise to pertinent information and are presumed relevant. VA's duty to assist requires that relevant SSA records be obtained. See Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2009). VA Treatment Records The Veteran informed VA during her August 2011 hearing and again in her October 2011 letter, that she has undergone recent VA outpatient treatment. These records have not yet been associated with the claims file. VA treatment records are considered part of the record on appeal since they are within VA's constructive possession. Bell v. Derwinski, 2 Vet. App. 611, 613 (1992). Currently, the most recent VA treatment record in the claims folder is dated April 2004. Therefore, requests for VA medical records should be made to ensure that all pertinent evidence is reviewed. Examinations Additional development is also required regarding VA's duty to afford examinations. In McLendon v. Nicholson, 20 Vet. App. 79 (2006), the United States Court of Appeals for Veterans Claims (Court) discussed the steps to be taken in determining whether a VA examination is necessary prior to final adjudication of a claim. In disability compensation claims, the Secretary must provide a VA medical examination when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service, or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran's service or with another service-connected disability, but (4) there is insufficient competent medical evidence on file for the Secretary to make a decision on the claim. 38 U.S.C.A. § 5103A(d)(2), 38 C.F.R. § 3.159(c)(4)(i). The Court in McLendon observed that the third prong, which requires that the evidence of record "indicates" that the claimed disability or symptoms "may be" associated with the established event, is a low threshold. McLendon, 20 Vet. App. at 83. In her lay statements, including her August 2011 hearing, the Veteran stated that she was first diagnosed with PTSD shortly after returning from her second period of service after her employer sent her to counseling in response to problems related to alcohol. The Veteran also has stated that she believes these symptoms began in service as a result of a claustrophobia-induced panic attack she suffered during a drill while on active duty. With regard to her hypertension claim, the Veteran has attributed this to her claimed PTSD. Additionally, the Board notes that at the time of her separation examination in November 1991, the Veteran's blood pressure was 130/90. Under Diagnostic Code (DC) 7101, note 1, the term "hypertension" is defined as diastolic blood pressure that is predominantly 90mm. or greater, and isolated systolic hypertension is defined as systolic blood pressure that is predominantly 160mm. or greater, with a diastolic blood pressure of less than 90mm. See 38 C.F.R. § 4.104. While one high blood pressure reading may not be sufficient to establish in-service hypertension, it is sufficient to trigger additional medical inquiry. Finally, the evidence of record confirms the Veteran's complaints of a cerebrovascular accident, which she has related to PTSD. Thus, the issue of service connection for cerebrovascular accident is intertwined with the issue of service connection for PTSD so that an opinion causally linking any current acquired psychiatric disability to the Veteran's military service would trigger VA's duty to provide a medical examination for this disability. Insofar as this disability may alternately be causally linked to the Veteran's service connected hypertension, a positive nexus opinion on this disability would likewise trigger VA's duty to provide such an examination. Based on the above, examinations on the issues of service connection for an acquired psychiatric disability (claimed as PTSD) and hypertension are deemed necessary. If one or both of those examinations yield a positive nexus opinion, an examination and opinion on the relationship between the Veteran's cerebrovascular accident and any service connected disability would also be necessary. Accordingly, the case is REMANDED for the following action: 1. Assist the Veteran in obtaining complete treatment records from Dr. Hungerford in approximately 1991, and Dr. Merritt in approximately 1999. 2. Take appropriate action to contact SSA in order to obtain copies of records pertinent to the Veteran's claim for SSA benefits. If the records are not available, a notation to that effect should be made in the claims folder and communicated to the Veteran. 3. Obtain all VA treatment records not previously obtained, particularly those dated after April 2004 pertaining to the Veteran's PTSD, hypertension, and/or residuals of stroke. All records obtained pursuant to this request must be included in the Veteran's claims file. If the search for such records has negative results, this should be documented in the record and communicated to the Veteran. 4. Upon completion of any stressor development deemed necessary, schedule the Veteran for a VA psychological examination with a psychologist or psychiatrist to determine the nature and etiology of any acquired psychiatric disorder found to be present. The claims file should be made available to the examiner and reviewed in conjunction with this examination. Specifically, the VA examiner should address the following questions: a. Does the Veteran currently suffer from an acquired psychiatric disorder, including PTSD? b. If so, is it at least as likely as not than any currently diagnosed acquired psychiatric disorder first manifested in service or is otherwise attributable to the in-service claustrophobia-induced panic attack, or other incident of service? c. With respect to any diagnosis of PTSD, is it at least as likely as not than any current diagnosis is attributable to an in-service stressor and, if so, identify the stressor(s) responsible for her PTSD? The examiner should provide all examination findings, along with the complete rationale for each opinion expressed and conclusion reached. 5. Schedule the Veteran for a VA examination with an examiner with the appropriate expertise to determine the nature and etiology of any current hypertension. The claims file should be made available to the examiner and reviewed in conjunction with this examination. Specifically, the VA examiner should address the following question: Whether it is at least as likely as not that the Veteran's hypertension began in service or is otherwise attributable to the Veteran's military service, to include her possible elevated diastolic blood pressure reading at the time of her separation examination? The examiner should provide all examination findings, along with the complete rationale for each opinion expressed and conclusion reached. 6. If a positive medical nexus opinion is provided linking either an acquired psychiatric disability or hypertension to the Veteran military service, schedule her for a VA examination with an examiner with the appropriate expertise to determine the nature and etiology of any disability associated with her cerebrovascular accident. The claims file should be made available to the examiner and reviewed in conjunction with this examination. Specifically, the VA examiner should address the following questions: a. Does the Veteran currently have a disability associated with her cerebrovascular accident? b. If so, is it at least as likely as not than any such current disability was caused and/or aggravated beyond the normal progress of the disorder by her military service, her hypertension, or any acquired psychiatric disability? The examiner should provide all examination findings, along with the complete rationale for each opinion expressed and conclusion reached. 7. Thereafter, the RO/AMC should readjudicate the claims in light of the additional evidence obtained. If the benefits sought on appeal remain denied, the Veteran and her representative should be provided a supplemental statement of the case. An appropriate period of time should then be allowed for a response, before the record is returned to the Board for further review. 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 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 Supp. 2011). _________________________________________________ T. MAINELLI Acting 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) (2011).