Citation Nr: 1736799 Decision Date: 09/01/17 Archive Date: 09/19/17 DOCKET NO. 13-22 021A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUES 1. Entitlement to service connection for hypertension to include as secondary to service-connected posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for hepatitis B. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD B. Berry, Counsel INTRODUCTION The Veteran served on active duty from August 1966 to August 1968, to include service in Vietnam for which he was awarded, among other things, the Combat Infantryman Badge. These matters come to the Board of Veterans' Appeals (Board) on appeal from a rating decision dated in April 2013 by the Department of Veterans Affairs (VA) Regional Office (RO) in Detroit, Michigan. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if further action, on his part, is required. REMAND After review of the record, the Board finds that further AOJ action on these claims is warranted, even though such will, regrettably, further delay an appellate decision on these matters. With respect to the issue of entitlement to service connection for hypertension, the Veteran was afforded a VA examination in February 2013. The VA examiner determined that the Veteran's hypertension is less likely than not proximately due to or the result of the Veteran's service-connected PTSD. The examiner noted that an increase in blood pressure is a normal response to stress, the blood pressure change tend to return to normal following removal of the stress. The Veteran's blood pressure and heart rate have been stable, which is the opposite finding one would expect from stress related PTSD. He has not had dosage changes in his antihypertensive medication. The examiner concluded that the preponderance of the evidence does not support PTSD as an etiology for this Veteran's hypertension. The Board notes that the VA examiner's explanation in support of his medical opinion does not address the issue of aggravation. Furthermore, the Veteran submitted a medical article discussing hypertension in relation to PTSD and depression. The Board also notes that VA's own statements in connection with its rulemaking authority support an association between PTSD and hypertension. VA has found that a presumption of service connection is warranted for hypertensive vascular disease for prisoners of war (POWs). This presumption is based on several medical studies indicating that veterans who have a long-term history of PTSD have a high risk of developing cardiovascular disease and myocardial infarction; thus, since POWs have a relatively high rate of PTSD incurrence, they would presumably be at greater risk of cardiovascular disease to include hypertension. See Presumptions of Service Connection for Diseases Associated With Service Involving Detention or Internment as a Prisoner of War, 70 Fed. Reg. 37040 (June 28, 2005); Presumptions of Service Connection for Diseases Associated With Service Involving Detention or Internment as a Prisoner of War, 69 Fed. Reg. 60083 (Oct. 7, 2004). This information was not addressed in the February 2013 VA medical opinion. The Veteran DD Form 214 reflects that the Veteran engaged in combat with the enemy while stationed in Vietnam and although the Veteran was not a POW, the Board finds that the VA material is relevant to the Veteran's claim. Therefore, the VA medical opinion should consider and discuss the above medical articles and studies. Regarding the Veteran's service connection claim for hepatitis B, a VA treatment record dated in October 2012 document that the Veteran's hepatitis B surface antibody (HBsAb) result was reactive indicating that the Veteran was exposed to the hepatitis B virus or the vaccine. There was a notation to inquire whether the Veteran was immunized with the Hepatitis B vaccine. A November 2012 addendum noted that the Veteran was never vaccinated for hepatitis B. A lab was ordered in November 2012 to check HBsAg (hepatitis B surface antigen) to determine infection. The claims file does not contain the results of any further testing for hepatitis B. The Board notes that the medical evidence indicates that the Veteran was exposed to hepatitis B and the Veteran contends that he has residuals of hepatitis B to include fatigue. The Veteran asserts that his hepatitis B or residuals thereof are due to being exposed to blood from fellow soldiers during combat in Vietnam. The Veteran's DD Form 214 reveals that the Veteran was awarded the Combat Infantryman Badge for his service in Vietnam, which reflects that the Veteran engaged in combat with the enemy. See VA Adjudication Procedures Manual, IV.ii.1.D.1.e (updated March 31, 2017) (list of Decorations that are evidence of combat participation). Exposure to fellow soldiers' blood during combat is consistent with the circumstances of the Veteran's combat service, and thus, the Board will concede that he came into contact with other service members' blood during active military service. See 38 U.S.C.A. § 1154(b) (West 2014). Accordingly, the Veteran should be provided with a VA examination to determine whether the Veteran has a current diagnosis of hepatitis B or any residuals of hepatitis B, and if so, whether it is caused by or related to any risk factors that occurred during active military service to include exposure to blood from fellow soldiers during combat in Vietnam. Accordingly, the case is REMANDED for the following action: 1. Arrange to obtain a medical opinion from an appropriate physician with respect to the Veteran's service connection claim for hypertension. The contents of the entire, electronic claims file (in VBMS and Virtual VA), to include a complete copy of this REMAND, must be made available to the designated physician, and the addendum opinion/examination report should reflect full consideration of the Veteran's documented medical history and lay assertions. The physician is requested to review all pertinent records associated with the claims file (particularly the blood pressure readings during service and separation examination) and offer an opinion as to whether the Veteran's hypertension is at least as likely as not (i.e., a fifty percent or greater probability) related to the Veteran's active military service. If the answer is negative, then the examiner is asked to provide an opinion on whether it is at least as likely as not (i.e., a fifty percent or greater probability) the Veteran's hypertension was caused by or aggravated by his service-connected PTSD. The examiner should explain the reasoning for his or her opinion to include the evidence relied upon and rejected in reaching the opinion. The examiner is asked to review and discuss pertinent studies and/or medical articles as part of his or her opinion with respect to whether the Veteran's hypertension is caused by or aggravated by his PTSD to include the articles submitted by the Veteran and the VA material cited above (Presumptions of Service Connection for Diseases Associated With Service Involving Detention or Internment as a Prisoner of War, 70 Fed. Reg. 37040 (June 28, 2005); Presumptions of Service Connection for Diseases Associated With Service Involving Detention or Internment as a Prisoner of War, 69 Fed. Reg. 60083 (Oct. 7, 2004)) suggesting an association between PTSD and hypertension. 2. Arrange for the Veteran to undergo an appropriate VA examination with respect to his service connection claim for hepatitis B. The contents of the entire, electronic claims file (in VBMS and Virtual VA), to include a complete copy of this REMAND, must be made available to the examiner for review. All indicated tests and studies should be accomplished. After completion of the examination and review of the evidence, the examiner should provide the following opinions: a. Does the Veteran have a current diagnosis of hepatitis B at any time during the appeal period or any residuals thereof (to include fatigue)? b. If the Veteran is found to have a current diagnosis of hepatitis B or any residuals thereof, is it at least as likely as not (i.e., a fifty percent or greater probability) that any current hepatitis B or residuals of hepatitis B was incurred during active service or related to any risk factors in service, to include exposure to fellow solders' blood during combat in Vietnam. A complete explanation must be provided for all opinions. If the examiner cannot provide an opinion without resort to speculation, the examiner should provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made. 3. Upon completion of the foregoing, readjudicate the Veteran's claims on appeal, based on a review of the entire evidentiary record. If any benefits sought on appeal remains denied, provide the Veteran and his representative with a supplemental statement of the case and the opportunity to respond thereto. Thereafter, subject to current appellate procedure, the case should be returned to the Board for further consideration, if in order. 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). These claims 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 2014). _________________________________________________ Jonathan Hager Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2014), 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) (2016).