Citation Nr: 18143311 Decision Date: 10/18/18 Archive Date: 10/18/18 DOCKET NO. 16-01 246 DATE: October 18, 2018 REMANDED The issue of service connection for a recurrent lumbosacral spine disorder to include degenerative disc disease is remanded. The issue of service connection for a recurrent cervical spine disorder to include degenerative disc disease is remanded. The issue of service connection for a recurrent shoulder disorder is remanded. The issue of service connection for a recurrent heart disorder to include an irregular heartbeat is remanded. The issue of service connection for a recurrent gastrointestinal disorder to include irritable bowel syndrome (IBS) is remanded. The issue of service connection for hypertension is remanded. REASONS FOR REMAND The Veteran had active service from January 1967 to October 1970. 1. The issues of service connection for a recurrent lumbosacral spine disorder to include degenerative disc disease, a recurrent cervical spine disorder to include degenerative disc disease, and a recurrent shoulder disorder are remanded. The Veteran asserts that service connection for recurrent lumbosacral spine, cervical spine, and shoulder disabilities is warranted as the claimed disorders were incurred while he performed his military duties aboard the U.S.S. Hornet which involved “lifting, carrying, issuing and storing supplies and material in storerooms below decks.” The Veteran’s service treatment records reflect that he was seen for lumbar spine complaints. The report of the Veteran’s December 1966 physical examination for service entrance states that the Veteran’s spine was found to be normal. A February 1967 treatment record states that the Veteran presented a history of intermittent low back pain since a June 1966 motor vehicle accident. An impression of low back syndrome was advanced. The report of a May 2013 Department of Veterans Affairs (VA) thoracolumbar spine examination states that the Veteran was diagnosed with lumbosacral spine degenerative disc disease. The examiner concluded that the diagnosed lumbosacral spine disorder “was less likely as not (less than 50 percent probability) incurred in or caused by the claimed in service injury, event, or illness.” The VA physician’s assistant commented that the Veteran “was seen once for non injury back pain 2/1967;” “no evidence he was seen again in the service;” “no medical record indication he was seen for chronic back pain after the service;” and “he currently has mild age related DDD.” He did not note or otherwise address the in service notation that the Veteran’s lumbar spine complaints were initially manifested after a motor vehicle accident and the Veteran’s subjective history of chronic low back pain associated with heavy lifting during active service. The Veteran was not afforded VA examinations which addressed the cervical spine and the shoulders. VA’s duty to assist includes, in appropriate cases, the duty to conduct a thorough and contemporaneous medical examination which is accurate and fully descriptive. McLendon v. Nicholson, 20 Vet. App. 79 (2006); Green v. Derwinski, 1 Vet. App. 121, 124 (1991). When VA undertakes to obtain an evaluation, it must ensure that the evaluation is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Given the cited deficiencies in the May 2013 VA examination report, the Board of Veterans' Appeals (Board) finds that further VA spine and shoulder evaluations are needed to adequately address the issues raised by the instant appeal. Clinical documentation dated after January 2016 is not of record. VA should obtain all relevant VA and private treatment records which could potentially be helpful in resolving the Veteran’s claims. Murphy v. Derwinski, 1 Vet. App. 78 (1990); Bell v. Derwinski, 2 Vet. App. 611 (1992). 2. The issues of service connection for a recurrent heart disorder to include an irregular heartbeat, a recurrent gastrointestinal disorder to include IBS, and hypertension are remanded. The Veteran contends that service connection for recurrent heart, gastrointestinal, and hypertensive disabilities are warranted as the claimed disorders were either caused or aggravated by the service connected psychiatric disabilities. Service connection may also be granted for disability which is proximately due to or the result of a service connected disease or injury. 38 C.F.R. § 3.310(a). Service connection shall be granted on a secondary basis under the provisions of 38 C.F.R. § 3.310(a) where it is demonstrated that a service connected disorder has aggravated a nonservice connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). Service connection is currently in effect for posttraumatic stress disorder (PTSD) with a not otherwise specified anxiety disorder, a not otherwise specified depressive disorder, and alcohol abuse. A June 2011 written statement from A. Qadri, M.D., relates that he had treated the Veteran since December 2009 for an irregular heartbeat, IBS, and hypertension. The doctor concluded that the diagnosed disorders were “connected to his PTSD.” The report of a November 2015 VA heart examination states that the Veteran was diagnosed with “biatrial enlargement and left ventricular hypertrophy- this is most likely due to his hypertension.” The examiner concluded that “the condition claimed is less likely than not (less than 50% probability) proximately due to or the result of the Veteran’s service connected condition.” The VA physician’s assistant commented that “I am not aware of any medical literature that substantiates a claim that PTSD causes biatrial enlargement/left ventricular hypertrophy.” She did not address Dr. Qadri’s positive opinion as to the relationship of the disorder to the service connected PTSD. The report of a November 2015 VA gastrointestinal examination and a December 2015 addendum thereto state that the Veteran was diagnosed with IBS. The examiner concluded that “the condition claimed is less likely than not (less than 50% probability) proximately due to or the result of the Veteran’s service connected condition” and was not aggravated by the service connected PTSD. The VA physician’s assistant commented that “the cause of IBS is unknown.” She did not address Dr. Qadri’s positive opinion as to the relationship of the disorder to the service connected PTSD. The report of a November 2015 VA hypertension examination and a December 2015 addendum thereto state that the Veteran was diagnosed with hypertension. The examiner concluded that “the condition claimed is less likely than not (less than 50% probability) proximately due to or the result of the Veteran’s service connected condition” and was not aggravated by the service connected PTSD. The VA physician’s assistant commented that “although mental disease and stress can temporarily elevate blood pressure during an acute phase of the disease, I am not aware of any medical literature that substantiates a claim that PTSD permanently elevates the blood pressure.” She did not address Dr. Qadri’s positive opinion as to the relationship of the disorder to the service connected PTSD. Given the cited deficiencies in the November 2015 VA examination reports and the December 2015 addenda thereto, the Board concludes that further VA cardiovascular and gastrointestinal evaluations are necessary. The matters are REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for each private healthcare provider who has treated the recurrent lumbosacral spine, cervical spine, shoulder, cardiovascular, and gastrointestinal disabilities. Make two requests for any authorized records from all identified healthcare providers unless it is clear after the first request that a second request would be futile. 2. Obtain the Veteran’s VA treatment records associated with treatment after January 2016. 3. Schedule the Veteran for a VA spine examination conducted by a physician to assist in determining the current nature of any identified recurrent lumbosacral spine disability and recurrent cervical spine and its relationship, if any, to active service. The examiner must review the record and should note that review in the report. A rationale for all opinions should be provided. The examiner should: (a) Diagnose all recurrent lumbosacral spine and cervical spine disabilities found. (b) Opine whether it is at least as likely as not (50 percent probability or greater) that any identified recurrent lumbar spine disability and recurrent cervical spine disability had its onset during active service or is related to any incident of service, including the documented in service lumbar spine complaints. 4. Schedule the Veteran for a VA shoulder examination conducted by a physician to assist in determining the current nature of any identified recurrent shoulder disability and its relationship, if any, to active service. The examiner must review the record and should note that review in the report. A rationale for all opinions should be provided. The examiner should: (a) Diagnose all recurrent shoulder disabilities found. (b) Opine whether it is at least as likely as not (50 percent probability or greater) that any identified recurrent shoulder disability had its onset during active service or is related to any incident of service. 5. Schedule the Veteran for a VA cardiovascular examination conducted by a physician to assist in determining the current nature of any identified recurrent heart disability and hypertensive disability and its relationship, if any, to active service and/or service connected disability. The examiner must review the record, including Dr. Qadri’s June 2011 written statement, and should note that review in the report. A rationale for all opinions should be provided. The examiner should: (a) Diagnose all recurrent heart and hypertensive disabilities found. (b) Opine whether it is at least as likely as not (50 percent probability or greater) that any identified recurrent heart disability and hypertensive disability had its onset during active service or is related to any incident of service. Reconcile the opinion with the other opinions of record, including from Dr. Qadri. (c) Opine whether it is at least as likely as not (50 percent probability or greater) that any identified recurrent heart disability and hypertensive disability is due to the service connected disabilities. (d) Opine whether it at least as likely as not (50 percent probability or greater) that any identified recurrent heart disability and hypertensive disability has been aggravated (permanently increased in severity beyond the natural progress of the disorder) by the service connected disabilities. 6. Schedule the Veteran for a VA gastrointestinal examination conducted by a physician to assist in determining the current nature of any identified recurrent gastrointestinal disability and its relationship, if any, to active service and/or service connected disability. The examiner must review the record, including Dr. Qadri’s June 2011 written statement, and should note that review in the report. A rationale for all opinions should be provided. The examiner should: (a) Diagnose all recurrent gastrointestinal disabilities found. (b) Opine whether it is at least as likely as not (50 percent probability or greater) that any identified recurrent gastrointestinal disability had its onset during active service or is related to any incident of service. Reconcile the opinion with the other opinions of record, including from Dr. Qadri. (c) Opine whether it is at least as likely as not (50 percent probability or greater) that any identified recurrent gastrointestinal disability is due to the service connected psychiatric disabilities. (d) Opine whether it at least as likely as not (50 percent probability or greater) that any identified recurrent gastrointestinal disability has been aggravated (permanently increased in severity beyond the natural progress of the disorder) by the service connected psychiatric disabilities. J. T. HUTCHESON Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Denton, Buck