Citation Nr: 1318482 Decision Date: 06/06/13 Archive Date: 06/11/13 DOCKET NO. 08-26 415 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for a left arm disability (claimed as overuse syndrome of the left arm). 2. Entitlement to service connection for hypertension. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Megan C. Kral, Associate Counsel INTRODUCTION The Veteran served on active duty from December 2000 to March 2001 and from October 2001 to June 2002. The Veteran also had a period of Reserve service. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO), which denied the benefits sought on appeal. This case was previously before the Board in December 2011 when it was remanded for additional development of the evidence. However, as will be explained below, this claim must again be remanded to the RO via the Appeals Management Center (AMC). VA will notify the Veteran if further action is required. REMAND While the Board regrets the further delay that another remand of this case will cause, the record is not ready for appellate review of the issue on appeal. The following further development is required. In a previous (December 2011) remand, the Board sought a VA addendum opinion from the VA nurse practitioner who conducted the July 2010 examination. Specifically, the Board found the VA examiner failed to provide a rationale in support of his conclusions that the Veteran's left shoulder rotator cuff tear was less likely as not caused by, or the result of, her right shoulder and neck conditions. Additionally, the Board found the examiner failed to provide an opinion, as requested, as to whether the Veteran's right shoulder and neck conditions aggravated the left shoulder condition, to include overuse of the left arm. Although an addendum opinion was completed in February 2012, the VA examiner essentially reiterated his earlier findings; again failed to provide an adequate rationale as to his conclusion that the Veteran's left shoulder rotator cuff tear was less likely as not caused by, or the result of, her right shoulder and neck conditions; and failed to provide a rationale to support his determination that the Veteran's service-connected cervical and right shoulder conditions did not aggravate the left shoulder. Therefore, an additional examination and opinion must be obtained. Further, the previous remand requested the July 2010 VA examiner provide an opinion as to whether the Veteran's hypertension was proximately due to, the result of, or aggravated by medications used to alleviate pain. The examiner stated he was unable to determine any medications which would increase the patient's blood pressure. However, the Veteran's representative has submitted literature which suggests that the medication, Diclofenac, which the Veteran is prescribed, may cause an increased risk of serious cardiovascular risks. As the Board cannot draw its own medical conclusions as to the potential side effects of the Veteran's pain medication, an additional medical opinion is necessary to determine whether the Veteran's use of Diclofenac caused or aggravated her hypertension. See Colvin v. Derwinski, 1 Vet. App. 171 (1991). Accordingly, the case is REMANDED for the following action: 1. The RO should obtain any updated VA treatment records (not already of record) relevant to the appeal. 2. The RO should schedule the Veteran for a VA examination by a medical doctor to address the nature, extent and etiology of her left arm disability. It is imperative that the claims file be made available to the opinion provider for review. Any medically indicated special tests should be accomplished. After reviewing the claims file and examining the Veteran, the examiner should respond to the following: Is it at least as likely as not (a 50% or higher degree of probability) that the Veteran's service-connected cervical degenerative disc disease and right shoulder condition proximately caused or aggravated her left shoulder disability, to include as due to overuse of the left arm? A detailed rationale for all opinions should be provided addressing the posed question regarding both causation and aggravation. 3. A medical opinion, with examination only if deemed necessary, by a medical doctor, should be provided. It is imperative that the claims file be made available to the opinion provider for review. Based on a review of the claims file, the provider must provide an opinion as to: Is it at least as likely as not (a 50 percent or higher degree of probability) that the Veteran's hypertension is proximately caused by or aggravated by medication used to alleviate chronic pain from the Veteran's service-connected cervical degenerative disc disease and right shoulder condition, to include the use of Diclofenac? A detailed rationale for all opinions should be provided addressing the posed question regarding both causation and aggravation. The provider is also requested to comment on the literature provided by the Veteran's representative. 4. In the interest of avoiding further remand, the RO should review the medical opinions obtained and ensure that adequate opinions with rationale have been offered. 5. After completion of the above and any further development deemed necessary by the RO, the issues on appeal should be readjudicated. If the benefits sought is not granted, the Veteran and her representative should be furnished an appropriate supplemental statement of the case and be afforded an opportunity to respond. Thereafter, the case should be returned to the Board for further appellate review. The Veteran 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. 2012). _________________________________________________ ALAN S. PEEVY 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).