Citation Nr: 1336188 Decision Date: 11/06/13 Archive Date: 11/13/13 DOCKET NO. 03-29 897 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas THE ISSUE Entitlement to service connection for hypertension, to include as secondary to the service-connected posttraumatic stress disorder (PTSD). REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Matthew Blackwelder, Counsel INTRODUCTION The Veteran had active service in the United States Navy from September 1943 to March 1946. This appeal comes to the Board of Veterans' Appeals (Board) from a September 2002 rating decision. This claim was previously remanded by the Board in December 2006, November 2008, February 2011, September 2012 and May 2013. In December 2006, the Board remanded the hypertension claim for notice regarding VA's duty to assist. In November 2008, it was remanded as inextricably intertwined with an unadjudicated claim for PTSD. In February 2011, the Board remanded, noting that the VA examiner had not addressed whether the Veteran's PTSD aggravated his hypertension. In September 2012, the Board remanded to allow the Veteran's private doctor the opportunity to provide a rationale for his opinion. Finally, in May 2013, the Board remanded to clarify the question of aggravation. The directed development has been completed, and because the Board's orders were fully complied with, there is no prejudice for the Board to proceed. See Stegall v. West, 11 Vet. App. 268 (1998). This appeal was processed using VA's paperless claims processing system (VBMS). Accordingly, any future consideration of this Veteran's case should take into consideration the existence of this electronic record. The Board must note that in reviewing this case the Board has not only reviewed the Veteran's VBMS file, but also his file on the "Virtual VA" system to insure a total review of the evidence. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). 38 U.S.C.A. § 7107(a)(2). In an August 2013 statement, the Veteran requested that he be granted a total disability rating based on individual unemployability (TDIU). This claim had previously been denied, but no substantive appeal was received following an April 2012 statement of the case. As such, this issue has again been raised by the record, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. FINDINGS OF FACT 1. Hypertension was not diagnosed in service, or shown to a compensable degree within one year of service, and high blood pressure is not shown to have been continuous since service. 2. Hypertension was not diagnosed for many years after service. 3. The evidence is against a finding that the Veteran's hypertension is causally or etiologically related to his military service. 4. The evidence is against a finding that the Veteran's hypertension was either caused or aggravated by a service connected disability, to include PTSD. CONCLUSION OF LAW Criteria for service connection for hypertension have not been met. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Service Connection Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection can be established on a presumptive basis, on a direct basis, or on a secondary basis. Each of these bases will be considered and discussed below. Presumptive Service Connection Service connection may be established under 38 C.F.R. § 3.303(b), if a chronic disease or injury is shown in service, and subsequent manifestations of the same chronic disease or injury at any later date, however remote, are shown, unless clearly attributable to intercurrent causes. For a showing of a chronic disorder in service, the mere use of the word chronic will not suffice; rather, there is a required combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. In this case, the Veteran has been diagnosed with hypertension which is listed as a "chronic disease" under 38 C.F.R. § 3.309(a); therefore, 38 C.F.R. § 3.303(b) applies. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (holding that the "chronic" in service and "continuous" post-service symptom presumptive provisions of 38 C.F.R. § 3.303(b) only apply to "chronic" diseases at 3.309(a)). Service connection may also be established with certain chronic diseases, including hypertension, based upon a legal presumption by showing that the disorder manifested itself to a degree of 10 percent disabling or more within one year from the date of separation from service. Such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. Here, the evidence of record does not show that the Veteran's hypertension was diagnosed in service or was manifested within a year of service. Service treatment records show that the Veteran's blood pressure was 114/74 at enlistment and 118/72 at his separation physical in March 1946. Hypertension was not diagnosed in the service treatment records, nor is there any indication that the Veteran was ever noted to have, or specifically treated for, elevated blood pressure. Thus, hypertension was not diagnosed in service. The limited medical evidence that is of record from the decade after the Veteran separated from service also fails to show a diagnosis of hypertension or elevated blood pressure. For example, the Veteran was hospitalized in April 1949 for five days for treatment of dermatitis at which time his blood pressure was 116/70 (i.e. a non-hypertensive level). There is no medical record of any treatment for hypertension in the years following service. As such, the evidence of record does not document a diagnosis of hypertension within a year of service. The Veteran has on occasion asserted that his hypertension began shortly after service. For example, in an undated statement in support of his claim, he reported having blood pressure problems as far back as 1948 when he recalled being certain he was having a heart attack because of chest pains and heart pounding. According to the Veteran, his family doctor at the time told him it was his nerves and put him on blood pressure medication and tranquilizers. Specifically, the Veteran recalled having blood pressure in the 90s and 100s, and being put on tenormin (a medication used for treatment of chest pain and high blood pressure) for years, but being eventually taken off because the medication was aggravating his lung problems. Another medication was reportedly then prescribed. The Veteran also recalled being sent to San Francisco in 1946, and being reportedly told he had combat fatigue. He reported staying there for a week and a half for R&R, but he denied being diagnosed with PTSD at that time, as PTSD did not become a recognized diagnosis for a number of years thereafter. The Veteran asserted that his hypertension had been ongoing for over 50 years and was therefore not just due to age. Yet, while the Veteran has at times asserted that his hypertension onset shortly after separation, he has also on repeated other occasions indicated that his hypertension was first diagnosed in the 1990s. For example, in November 2005, May 2006, May 2007, and May 2008 VA treatment records, the Veteran gave a history of essential hypertension since 1990. To the extent, the Veteran has asserted that his hypertension onset shortly after service, treatment with blood pressure medication is simply not shown by the evidence of record for many years after separation and is not reflected by the Veteran's own reported statements of medical history that were noted above. Lay testimony is competent to establish the presence of observable symptomatology and may provide sufficient support for a claim of service connection. Layno v. Brown, 6 Vet. App. 465, 469 (1994). For example, when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. In such cases, the Board is within its province to weigh that testimony and to make a credibility determination. See Barr v. Nicholson, 21 Vet. App. 303 (2007). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). As discussed, the Veteran's reports have been inconsistent in describing the onset of treatment, suggesting both that hypertension was treated shortly after service and that it was first diagnosed approximately forty years after service. Moreover, his assertion that his hypertension had existed for years, essentially since service or shortly thereafter, is contradicted by the contemporaneous evidence of record. See Curry v. Brown, 7 Vet. App. 59, 68 (1994) (noting that contemporaneous evidence has greater probative value than history as reported by a veteran). Specifically, the Veteran filed his first claim with VA in 1949, but did not seek service connection for hypertension or even mention high blood pressure at that time. In fact, he did not seek service connection for hypertension for multiple decades after service. While not dispositive on its face, this evidence weighs against the Veteran's claim. Similarly, the Veteran was hospitalized in April 1949 for five days for treatment of dermatitis, at which time his blood pressure was 116/70 (i.e. a non-hypertensive level). Had the Veteran in fact been having problems with hypertension, or been on medication for it, it would seem likely that he either would have sought service connection for it or that it would at least have been documented in the hospitalization records. See Kahana v. Shinseki, 24 Vet. App. 428, 439 (2011). The fact that he did not and it was not, also weighs against a finding of continuity. Given that the contemporaneous evidence contradicts the Veteran's allegation and that he has been inconsistent in his reports, the Board finds that his statements are insufficient on their own to establish the onset of hypertension or elevated blood pressure shortly in the year after service. VA did obtain a VA examination in March 2011 at which the Veteran asserted having developed hypertension shortly after separation and alleged that he was treated for it within one year after the discharged from the military. However, the examiner observed that the Veteran's service treatment records did not show hypertension and a diagnosis of hypertension was not of record until the 1990s. Given these findings, the Board concludes that the weight of the evidence makes it less likely than not that the Veteran's hypertension has existed continuously since service. Accordingly, service connection is not warranted on a presumptive basis. Direct Service Connection Even when a disease is first diagnosed after discharge, service connection may still be awarded if the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). This has been interpreted as a three-element test based on nexus: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred in or aggravated by service. See Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009). In his initial claim, in May 2002, the Veteran stated that he was seeking service connection for hypertension as secondary to asbestos exposure and lead paint exposure, but there has not been any medical suggestion that such exposure actually caused the Veteran's hypertension. As noted above, the medical evidence of record does not show that the Veteran's hypertension developed for a number of years after service. It was not shown in the service treatment records which contained blood pressure readings within normal limits; and it was not shown in the few medical records which are available within the first decade after the Veteran separated from service (such as the April 1949 hospitalization). In March 2011, the Veteran underwent a VA examination at which he asserted having developed hypertension since right after he got out of the service and was treated one year after discharge from the military. However, the examiner reviewed the Veteran's claims file, but found that his service treatment records did not show hypertension and that the record in March 1994 showed a diagnosis of hypertension for the first time. The medical professional opined that the Veteran's hypertension was neither caused by, nor the result of, the Veteran's military service. The Veteran disagreed with this finding in an August 2011 statement, but his disagreement appeared to largely be based on the amount of time the examiner spent conducting the physical examination. However, a physical examination is but one component of a medical opinion, and it is incumbent on the medical professional to take the amount of time needed to provide an opinion. Here, there is no suggestion that the examiner required any additional time with the Veteran to render an informed medical opinion. In February 2013 a VA cardiologist reviewed the Veteran's entire claims file and explained that hypertension is very common in the U.S. population especially the older population. He opined that because the Veteran's hypertension was diagnosed at an age of 70 years it was most likely genetic, noting that hypertension had not occurred while the Veteran was in the military or shortly after discharge. The Board notes that the Veteran has asserted on several occasions that he has experienced hypertension since service or shortly thereafter; and, lay testimony is competent to establish the presence of observable symptomatology and may provide sufficient support for a claim of service connection. Layno v. Brown, 6 Vet. App. 465, 469 (1994). Here, while the Veteran has made the assertion that he was treated with medication for his hypertension shortly after service, such a statement is not supported by any of the contemporaneous evidence. See Curry v. Brown, 7 Vet. App. 59, 68 (1994) (noting that contemporaneous evidence has greater probative value than history as reported by a veteran). As noted, the service treatment records including blood pressure readings taken at separation do not show hypertension or even elevated blood pressure, blood pressure taken during a hospitalization several years after service did not show hypertension, and the Veteran himself repeatedly told medical professionals that his hypertension was first diagnosed in the 1990s. Given the discrepancies in the Veteran's assertions, the Board finds that they are insufficiently credible to establish that his hypertension was first diagnosed or treated with close temporal proximity to his military service. In his initial claim, in May 2002, the Veteran stated that he was seeking service connection for hypertension as secondary to asbestos exposure and lead paint exposure, but there has not been any medical suggestion that such exposure during caused his hypertension, and the medical professional who provided the opinion, reviewed the Veteran's claims file, and was presumably aware of the Veteran's in-service exposures, but nevertheless found that his hypertension was most likely genetic in origin. Additionally, the Veteran lacks the medical training and expertise to provide a complex medical opinion as to the etiology of hypertension. See Layno v. Brown, 6 Vet. App. 465 (1994), Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). As such, his opinion is insufficient to provide the requisite nexus in this case. As described, the competent evidence is against a finding that it is at least as likely as not that the Veteran's hypertension either began during or was otherwise caused by his military service. As such, service connection on a direct basis is denied. Secondary Service Connection In addition to the regulations cited above, service connection is warranted for a disability which is aggravated by, proximately due to, or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. Any additional impairment of earning capacity resulting from an already service-connected condition, regardless of whether or not the additional impairment is itself a separate disease or injury caused by the service-connected condition, should also be compensated. Allen v. Brown, 7 Vet. App. 439 (1995). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. Id. The Veteran's main contention is that his hypertension was either caused or aggravated by his service connected PTSD. In February 2008 and again in May 2009, the Veteran asserted that the supporting evidence of hypertension was directly related to combat experience and the continual stress he was under during his service in the military. He noted that he did not have hypertension when he entered the service and he pointed out that there is a direct correlation between PTSD and hypertension. He asserted that his PTSD and the repetitive memories of combat caused the secondary condition of hypertension. In support of his claim, the Veteran has submitted a number of Board decisions in which service connection was granted for hypertension, to include as secondary to PTSD, which he believes are relevant to his claim and should be considered. The Board has in fact reviewed the submitted decisions; however, Board decisions are not precedential and are decided on the individual facts of the case. 38 C.F.R. § 20.1303. The Board does not dispute that in some cases, PTSD is shown to have caused hypertension. However, hypertension is not presumptively connected to PTSD, and therefore, the facts and medical evidence in each case must be considered in determining whether service connection is warranted for hypertension. In July 2009, Dr. Oh wrote that he had seen the Veteran since 1964 and that he had been taking Ambien and Xanax for the previous 3-4 years for nervousness, insomnia and probably PTSD. However, he made no mention of treating the Veteran for hypertension since 1964. In October 2011, Dr. Colgan, wrote that the Veteran had a history of chronic diastolic heart failure, atrial fibrillation and hypertension, as well as mitral and tricuspid valve regurgitation. He opined that it was more likely than not that the Veteran's cardiac conditions and hypertension were associated with and aggravated by PTSD that was a result of his combat exposure for three years in the South Pacific. However, Dr. Colgan failed to provide any rationale for his conclusions, and as the Board explained in the September 2012 remand, a medical opinion that contains only data and conclusions is not to be accorded any weight. See Nieves Rodriguez v. Peake, 22 Vet App 295 (2008). The Board nevertheless remanded the claim to allow Dr. Colgan an opportunity to clarify why he concluded that the Veteran's hypertension was related to his service connected PTSD, such as reference to pertinent details of the Veteran's medical history or citations to medical or scientific journals. A letter was sent to Dr. Colgan in September 2012, explaining why his opinion was considered inadequate for rating purposes and offering him the opportunity to clarify his opinion, but no addendum to his opinion appears to have ever been provided. The Veteran did submit a number of treatises which described research into the possible association between hypertension and PTSD. An article by Harold Cohen, Ph.D., suggested that studies had shown that people with PTSD were at an increased risk for a number of medical conditions such as hypertension. A psychologist at the National Center for PTSD also wrote that PTSD could cause secondary health problems such as cardiovascular disease, but also cautioned that the severity of the PTSD also had an impact. A statement from the Mayo Clinic noted that PTSD, high blood pressure and cardiovascular disease can be related as PTSD takes a physical toll on the body, explaining that a person may experience a faster heart rate, rapid breathing, sweating and/or dry mouth symptoms as part of a "fight or flight" response. The doctor suggested that prolonged repeated bouts of activation may lead to other medical problems or exacerbate symptoms of existing conditions, such as high blood pressure and heart disease. A blog article from June 2011, suggested that a University of California San Francisco study found that PTSD took a physical toll, such that those diagnosed with PTSD were found to be more likely to suffer from physical ailments such as heart disease or a stroke and nearly twice as likely to suffer from dementia. Research also showed blood flow to the brain during continuous fight or flight response situations led to chronic high blood pressure. Another article suggested that PTSD could lead to future heart attacks, but a commenter noted that the data did not track how frequently the men exercised, so researchers could not tell if the men with symptoms were getting more or less exercise than other veterans. Finally, an article from Health.com stated that U.S. troops in Iraq and Afghanistan who went into combat were more likely to develop high blood pressure over the long term than those in supporting roles. As described above, the Veteran has submitted a number of medical articles in attempting to link his hypertension to his service connected PTSD; and a medical article or treatise "can provide important support when combined with an opinion of a medical professional" if the medical article or treatise evidence discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least "plausible causality" based upon objective facts rather than on an unsubstantiated lay medical opinion. Mattern v. West, 12 Vet. App. 222, 228 (1999). However, in the present case, the treatise evidence submitted by the Veteran is not accompanied by the opinion of any medical expert which would explain how the studies are specifically relevant to the particular facts, circumstances, or symptoms of this Veteran's case. This fact is highly relevant as a VA examiner explained in July 2013 that the literature suggesting a possible link between PTSD and hypertension could not be used to support the Veteran's claim, because such an argument was too broad to be applicable or generalizable to every veteran with the diagnoses of hypertension and PTSD. Again, hypertension is not presumptively associated with PTSD. Thus, while the studies and articles may support a medical opinion, the studies alone are insufficient to establish the required medical nexus. To the extent that the Veteran has submitted additional articles that were not specifically described above, the Board notes that these additional studies, like those discussed do not attribute the Veteran's hypertension to his PTSD, but rather suggest generically that PTSD can cause or aggravate hypertension, a conclusion which is not in dispute in this case. While the treatise evidence does not in and of itself mandate a grant, it was sufficient to warrant a medical opinion as to whether the Veteran's PTSD either caused or aggravated his PTSD. In February 2013, a VA cardiologist reviewed the entire claims file and explained that hypertension is very common in the U.S. population, especially the older population. Given this fact, the examiner concluded that because the Veteran's hypertension was diagnosed at the age of 70, it was most likely genetic in etiology. The examiner noted hypertension never occurred while the Veteran was in the military or shortly after discharge (observations that are all supported by the record), and opined that it was not exacerbated, triggered, or caused by his PTSD. The examiner noted that PTSD was first diagnosed in 2007, many years after hypertension was diagnosed. The examiner opined that the claim that hypertension was caused by PTSD is medically unrealistic and unjustifiable. Because this opinion did not adequately address the question of aggravation, the Board remanded the claim for an addendum, which was provided in July 2013. The examiner, an associate chief of cardiology at a medical school, wrote that it was his opinion that the Veteran has had lonstanding, age-related, systemic hypertension, a very common medical condition at his age. He noted that the clinical diagnosis of PTSD was made many years later in 2007, many years after hypertension had been diagnosed. The examiner found that whether the Veteran had PTSD earlier than 2007 or whether his claim that he had the "nervous condition for which he was treated before 2007" was in fact un-diagnosed or un-recognized PTSD was not in the doctor's medical opinion supported by objective medical records and was merely hypothetical. As such, the examiner felt that this assertion could not be used as rational grounds to support either a causal relation or aggravation of his longstanding systemic hypertension by a subsequent diagnosis of PTSD, long after the diagnosis of systemic hypertension was made. Additionally, the examiner stated that aggravation of the Veteran's hypertension by PTSD was not documented in any of the medical records or notes by his treating doctor who was treating his hypertension. There were also no records documenting specific instances of acute flare-ups of his hypertension that were attributed to his PTSD, and there were no records documenting that the severity of the Veteran's hypertension or lack of response of his hypertension to anti-hypertensive medications or treatment were attributed to his PTSD. In summary, the examiner concluded that it was his medical opinion that the Veteran's hypertension was not aggravated and/or worsened by his service connected PTSD. While the Veteran believes that his PTSD caused or aggravated his hypertension, he, as a lay person, lacks the medical training and expertise to provide a complex medical opinion as to the etiology of his hypertension or any possible relationship between his hypertension and his PTSD. See Layno v. Brown, 6 Vet. App. 465 (1994), Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). As such, his opinion is insufficient to provide the requisite nexus in this case. As discussed, several medical opinions are of record, including the opinion from the Veteran's private doctor suggesting a relationship between the Veteran's hypertension and his PTSD. However, as noted, this opinion lacked any rationale for his conclusion. Specifically, while the doctor stated that it was as likely as not that the PTSD caused or aggravated the hypertension, he did not support this with any showing of the Veteran's hypertension actually worsening with PTSD spikes. Additionally, the private doctor did not establish when the Veteran's PTSD began, which means that his opinion simply did not address several highly relevant questions which would need to be answered to support a grant of service connection. First, if the Veteran's PTSD were alleged to have begun in service when his stressor occurred, why then was hypertension not diagnosed for more than 40 years thereafter? Conversely, if the Veteran's PTSD did not begin until 2006 when it was diagnosed, how was the hypertension which was diagnosed years earlier caused by it? Moreover, if the Veteran's hypertension was aggravated by the PTSD, how was it aggravated? The failure of the private doctor to answer these questions, significantly diminishes the probative value of this opinion. The Board offered Dr. Colgan an opportunity to bolster his opinion, but no addendum was received. The Board then obtained a medical opinion from a cardiologist who examined the specific facts of the Veteran's case, but ultimately concluded that the Veteran's PTSD neither caused, nor aggravated, his diagnosed hypertension. This opinion was supported by a complete rationale, and a clarifying addendum was obtained to ensure the adequacy of the opinion. Given that this opinion was grounded in the evidence of record, tailored to the specific facts of the Veteran's medical history, and supported by a complete rationale, it is found to be highly probative, and is afforded great weight. Given this conclusion, the weight of the competent evidence is against the finding that the Veteran's hypertension was either caused, or aggravated, by his PTSD. Therefore, service connection on a secondary basis is denied. II. Duties to Notify and Assist Under applicable criteria, VA has certain notice and assistance obligations to claimants. See 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). In the present case, required notice was provided by a letter dated in October 2010, and neither the Veteran, nor his representative, has either alleged, or demonstrated, any prejudice with regard to the content or timing of VA's notices or other development. See Shinseki v. Sanders, 129 U.S. 1696 (2009). As to VA's duty to assist, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). Private and VA treatment records have been obtained, as have service treatment records. Additionally, the Veteran was offered the opportunity to testify at a hearing before the Board, but he declined. The Veteran was also provided with several VA examinations (the reports of which have been associated with the claims file). The Board finds the most recent VA examination and subsequent addendum was thorough and adequate and provides a sound basis upon which to base a decision with regard to the Veteran's claim. In August 2013, the Veteran's representative argued that the medical opinion obtained on remand continues to be inadequate. His reasoning was that the examiner had rested his opinion upon the fact that none of the Veteran's care providers had linked an exacerbation of the hypertension to the PTSD. The representative argued that the Board was cognizant of that fact and was not seeking a summary of the record from the examiner, but instead was seeking an independent and original review and analysis of the record, even if that meant the examiner needed to be the one to compare and contrast the Veteran's ebbs and flows with both the PTSD and hypertension to identify the presence, or absence, of an association. The Board disagrees with this categorization of the obtained medical opinion as inadequate. The examiner reviewed the claims file, and answered the Board's questions directly, referencing the evidence of record to support his conclusions. The examiner specifically added that he did not see any spikes in his review, meaning that he did appear to address the very problem which the representative suggested made the opinion inadequate. As such, this opinion is found to be fully adequate and remand is not warranted. As described, VA has satisfied its duties to notify and assist, and additional development efforts would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). Because VA's duties to notify and assist have been met, there is no prejudice to the Veteran in adjudicating this appeal. ORDER Service connection for hypertension, to include as secondary to PTSD, is denied. ____________________________________________ MICHELLE L. KANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs