Citation Nr: 1330647 Decision Date: 09/24/13 Archive Date: 09/30/13 DOCKET NO. 11-05 951 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to service connection for hypertension, to include as secondary to service-connected hemorrhoids. 2. Entitlement to service connection for a genitourinary disability, claimed as urinary tract infections and urinary incontinence. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD A.J. Turnipseed, Counsel INTRODUCTION The Veteran served on active duty from August 1977 to February 1980. This matter comes before the Board of Veterans' Appeals (Board) from a September 2010 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) above. In June 2013, the Veteran testified before the undersigned Acting Veterans Law Judge via video conference. A transcript of the hearing is associated with the claims file. In addition to the paper claims file, there is an electronic claims file in Virtual VA which contains documents that are duplicative of those contained in the paper claims file or are irrelevant to the instant claim. The issue of entitlement to service connection for headaches, claimed as secondary to a traumatic brain injury, has been raised by the record, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). See June 2012 Written Brief Presentation. Therefore, the Board does not have jurisdiction over that issue, and it is referred to the AOJ for appropriate action. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the Veteran if further action is required on her part. REMAND Unfortunately, the record as it stands is currently inadequate for the purpose of rendering a fully informed decision as to the claims on appeal. Where the record before the Board is inadequate to render a fully informed decision, a remand is required in order to fulfill its statutory duty to assist the Veteran to develop the facts pertinent to the claim. Ascherl v. Brown, 4 Vet. App. 371, 377 (1993). With respect to the claim of service connection for hypertension, the Veteran has asserted that she believes her current diagnosis of hypertension is directly related to service or, in the alternative, is secondary to her service-connected hemorrhoids disability. As to direct service connection, the Veteran testified that, in approximately 1978, she began to experience dizziness, blurred vision, and intermittent elevated blood pressure readings. She testified that her symptoms continued after service and resulted in a diagnosis of hypertension shortly after service. In this regard, the Veteran testified that she continues to currently experience the same symptoms and the medical evidence shows that her diagnosis of hypertension has been continued throughout the pendency of this appeal. See VA treatment records dated from 1999 to 2011. The service treatment records (STRs) do not show that the Veteran manifested elevated blood pressure readings during service or that she was diagnosed with hypertension therein. Instead, the STRs show that the Veteran reported having high or low blood pressure on reports of medical history dated October 1979 and January 1980. While this evidence does not establish a diagnosis of hypertension during service, this evidence is consistent with the Veteran's competent report of experiencing high blood pressure readings during service. In support of her claim, the Veteran relies upon an undated statement submitted by Dr. H.J., which states that the Veteran's hypertension began on active duty, as is substantiated by records dating back to 1980. Dr. H.J. did not identify the specific evidence which shows a diagnosis of hypertension in the 1980s and, thus, his opinion is afforded lessened probative value, as the Board is unable to locate any records that show a diagnosis, or even findings, of hypertension during the 1980s. Nevertheless, Dr. H.J.'s opinion indicates that the Veteran's current hypertension may be related to her military service, which triggers VA's duty to provide the Veteran with a VA examination. See 38 C.F.R. § 3.326; McLendon v. Nicholson, 20 Vet. App. 79 (2006). As to secondary service connection, the Veteran testified that her service-connected hemorrhoids disability causes aches, pain, and stress, which she believes causes her blood pressure to increase. The evidentiary record does not contain a medical opinion that addresses whether the Veteran's hypertension is proximately due to, a result of, or aggravated by her service-connected hemorrhoids disability. Accordingly, on remand, the VA examiner will be requested to address the secondary service connection aspect of the hypertension claim. With respect to the claim of service connection for a genitourinary disability, the Veteran testified that she first began to experience problems with incontinence in approximately 1979 and that she experienced recurrent urinary tract infections (UTIs) from 1978 to 1979. She testified that her UTIs continued after service and that she experienced one UTI every month last year. The STRs show that, in February 1979, the Veteran sought treatment for pain while urinating, which she reported had persisted for three days. The diagnosis was a UTI. The Veteran was noted to have urinary tract symptoms with a urethral abscess in June 1979 and, in May 1980, she reported having to urinate frequently. The post-service treatment records show that the Veteran was diagnosed with a UTI in February 2000 and she also complained of urinary incontinence in May 2000. There is, however, no medical evidence of any genitourinary symptoms since October 2009, when the Veteran filed her service connection claim. In fact, the Veteran was afforded a VA genitourinary examination in July 2010 where there was no objective evidence of a UTI at the time and the examiner noted the claims file did not contain evidence of recurrent UTIs beyond the Veteran's subjective reports. Nevertheless, the Veteran is competent to report her current symptoms and, thus, her report of experiencing recurrent UTIs after service and to the present is considered competent lay evidence of such, despite the lack of medical evidence. Notably, the July 2010 VA examiner stated that the Veteran reported other genitourinary symptoms, including voiding every two hours during the day and night and incontinence. The VA examiner did not, however, state if the Veteran's symptoms represent a chronic genitourinary disability, other than a UTI. As there remains a question as to whether the Veteran currently has a genitourinary disability, including a UTI or other disability manifested by incontinence, on remand, the RO should obtain an addendum report from the July 2010 VA examiner. Finally, the evidentiary record contains VA outpatient treatment records dated from 1999 to 2011. On remand, all outstanding VA treatment records dated from 2011 to the present should be obtained and associated with the claims file. Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). Expedited handling is requested.) 1. Obtain any outstanding VA treatment records dated from February 2011 to the present and associate them with either the paper or paperless claims file (Virtual VA). Duplicate treatment records need not be associated with the record. Any negative attempts to obtain this evidence must be documented in the claims file. 2. After any new evidence is obtained, schedule the Veteran for an appropriate VA examination to determine the likely etiology of her current hypertension. The claims file must be made available to the examiner for review in conjunction with the examination and the examination report should reflect that such review was conducted. The examiner should provide an opinion as to each of the following: a. Does the Veteran have a current diagnosis of hypertension? b. Was hypertension present or diagnosed during the Veteran's first post-service year? c. Is it as likely as not (i.e., a probability of 50 percent or more) that the Veteran's current hypertension was incurred in or is otherwise related to her military service. In answering the foregoing, the examiner should consider the reports of medical history dated October 1979 and January 1980, which show the Veteran reported having high or low blood pressure on reports of medical history dated October 1979 and January 1980. The examiner must also consider all lay and medical evidence of record, including all lay evidence of continuity of symptomatology after service. d. Is it as likely as not (i.e., a probability of 50 percent) that the current left arm disability is proximately due the Veteran's service-connected hemorrhoids disability? e. Is it as likely as not (i.e., a probability of 50 percent) that the Veteran's hypertension is aggravated by her service-connected hemorrhoids disability? f. A rationale must be provided for each opinion offered. If the foregoing cannot be answered on a medical or scientific basis without invoking processes relating to guesswork or judgment based upon mere speculation, the examiner must clearly specify in the examination report why this is so. 3. Request that the physician who conducted the July 2010 VA genitourinary examination review the claims file, including this Remand, and address the following: a. A diagnosis of any currently manifested genitourinary disability should be rendered. The physician must specifically state if the Veteran's symptoms of incontinence and voiding every two hours during the day and night are indicative of a chronic genitourinary disability. b. If more than one genitourinary disability is identified, the VA examiner must identify the symptoms and functional impairment caused by each disability. If the examiner is unable to determine which symptoms are attribute to each disability, the examiner must clearly state such in the examination report and specify why this is so. c. For each disability identified on examination, the examiner is requested to offer an opinion as to whether it is at least as likely as not (i.e., a probability of 50 percent or more) that the identified genitourinary disability was incurred in or is otherwise related to her military service. In answering the foregoing, the examiner should address the service treatment records which show that the Veteran was diagnosed with a UTI in February 1979, manifested urinary tract symptoms with a urethral abscess in June 1979 and reported having to urinate frequently in May 1980. The examiner must also consider all lay and medical evidence of record, including all lay evidence of continuity of symptomatology after service. d. A rationale must be provided for each opinion offered. If the foregoing cannot be answered on a medical or scientific basis without invoking processes relating to guesswork or judgment based upon mere speculation, the examiner must clearly specify in the examination report why this is so. 4. After all of the above actions have been completed, readjudicate the claim on appeal. If the claims remain denied, issue to the Veteran and her representative a supplemental statement of the case, and afford the appropriate period of time within which to respond thereto. Thereafter, the case should be returned to the Board for further appellate consideration, if otherwise in order. The Board intimates no opinion as to the ultimate outcome of this case. The Veteran need take no action unless otherwise informed, and she has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). The Veteran is hereby notified that it is her responsibility to report for the examination and to cooperate in the development of the case, and that the consequences of failure to report for a VA examination without good cause may result in the claim being rated on the evidence of record or denial of the claim. 38 C.F.R. § 3.655 (2012). 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). _________________________________________________ JENNIFER HWA 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) (2012).