Citation Nr: 1305069 Decision Date: 02/12/13 Archive Date: 02/21/13 DOCKET NO. 10-36 271 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to service connection for a right shoulder disorder. 2. Entitlement to service connection for a kidney disorder. 3. Entitlement to service connection for a blood disorder, diagnosed as anemia and hyperkalemia. 4. Entitlement to service connection for headaches. REPRESENTATION Appellant represented by: Calvin Hansen, Attorney ATTORNEY FOR THE BOARD B. Thomas Knope, Counsel INTRODUCTION The Veteran served on active duty from April 1970 to March 1973. This matter is on appeal from a July 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas. The appeal is REMANDED to the Department of Veterans Affairs Regional Office. VA will notify the appellant if further action is required on his part. REMAND As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). In this case, the Board determines that additional development is required before these claims may be adjudicated. First, in May 2010, the Veteran informed VA that he submitted a claim for benefits with the Social Security Administration (SSA). While it is unclear whether the SSA ever made a ruling on this application, he has also indicated that he submitted medical evidence in support of his claim that may be relevant to the claims on appeal. VA is required to obtain relevant records held by any Federal department or agency that the claimant adequately identifies and authorizes the Secretary to obtain. Therefore, these records must be acquired. 38 U.S.C.A § 5103A(c)(3); Diorio v. Nicholson, 20 Vet. App. 193, 199-200 (2006); Tetro v. Gober, 14 Vet. App. 100, 108-09 (2000); Murincsak v. Derwinski, 2 Vet. App. 363, 372 (1992). Next, the Veteran's service treatment records reflect symptoms related to the claimed disorders during active duty service. Specifically, in a January 1973 private psychiatric evaluation, he was noted to experience "various psychosomatic problems," to include right shoulder pain, kidney pain and daily headaches. These complaints were reiterated during a military psychiatric consultation in February 1973. Moreover, a March 1971 treatment note indicates that he was evaluated for "mild anemia" that had been discovered during a routine physical examination. While further testing was performed, it is unclear whether he showed symptoms of a chronic blood disorder. The post-service treatment records indicate that the Veteran received treatment for disorders since leaving active duty which may potentially be related to his in-service complaints. For example, treatment records in May and June 2010 reflect that he was diagnosed with hyperkalemia, or elevated potassium in the blood, and that he was treated for anemia in July 2012. Moreover, the record reflects that he complained of left flank pain since as early as 1988, and was eventually diagnosed with chronic kidney disease. A history of headaches was observed in February 2012 and, in August 2008, he complained of shoulder pain, although this may be more related to a motor vehicle accident he experienced in 2000. The Board notes that the evidentiary threshold that is necessary to trigger VA's duty to assist in terms of obtaining a VA examiner's opinion is low. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). Contrary to the RO's conclusion that the Veteran was not actually diagnosed with any of these disorders in service, only evidence that establishes an "in-service event, injury or disease" is required. Such was shown here, and there is clinical evidence that any or all of these disorders may currently exist. Therefore, a VA examination and opinion is required prior to adjudicating these claims. Accordingly, the case is REMANDED for the following action: 1. Acquire any treatment records that may be available from the VA Medical Center in San Antonio, Texas, since July 2012. If the Veteran has undergone any private treatment for any of the claimed disorders on appeal, and the records of such treatment have not been associated with the claims file, such records should also be acquired after obtaining his authorization. 2. Obtain the Veteran's SSA records, including the medical evidence used to determine disability eligibility. If no SSA records are available, it should be so noted in the claims file. 3. Following completion of the above, afford the Veteran an appropriate VA examination to determine the nature, extent, onset and etiology of any chronic headaches, as well as any kidney, blood, and right shoulder disorder that may be found present. The claims folder should be made available to and reviewed by the examiner. All indicated studies deemed necessary by the examiner should be performed, and all findings of these tests should be reported in detail. The examiner should express an opinion as to whether it is at least as likely as not (i.e., a 50% possibility or greater) that any chronic headaches, as well as any kidney, blood, and right shoulder disorder, had their onset in or are otherwise etiologically related to active service. If DBQs are utilized, the RO should ensure that all appropriate DBQ forms are provided to address the relevant disorders. All opinions must be accompanied by adequate reasons and bases. Such reasons and bases may include, but are not limited to, discussion of the presence of symptomatology in service, specifically cited medical literature, and discussion of past evidence in the record, especially prior VA examination reports. The examiner must consider the Veteran's lay statements regarding the incurrence of these disorders, and the continuity of symptomatology. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation stating why this is so. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). 4. After completion of the foregoing, readjudicate the claims on appeal. If the benefits sought remain denied, the Veteran and his representative must be furnished a supplemental statement of the case and be given an opportunity to submit written or other argument in response before the claims file is returned to the Board for further appellate consideration. 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 Supp. 2012). _________________________________________________ BARBARA B. COPELAND 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) (2012).