Citation Nr: 18143949 Decision Date: 10/22/18 Archive Date: 10/22/18 DOCKET NO. 15-07 320 DATE: October 22, 2018 REMANDED Service connection for an acquired psychiatric disorder, to include depression, anxiety, and posttraumatic stress disorder (PTSD), is remanded. Service connection for hypertension (HTN) is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from March 1968 to November 1973 with service in Vietnam from December 1969 to November 1970. The Veteran attended a Videoconference Hearing before the undersigned Veterans Law Judge (VLJ) in May 2018. A transcript of that proceeding has been prepared and is associated with the file. 1. Service connection for an acquired psychiatric disorder, to include depression, anxiety, and posttraumatic stress disorder (PTSD), is remanded. In conjunction with the Veteran’s claim for PTSD, he was afforded a VA examination in May 2013. However, that examination was inadequate as the examiner did not address the diagnosis of anxiety disorder (November 2012), nor did the examiner provide an opinion as to whether the Veteran’s diagnosed depressive disorder, not otherwise specified, was related to his service. Moreover, the Veteran has submitted statements, and has testified that while in Vietnam he was assigned to Pleiku, which he described as “Rocket City” because of the daily rocket attacks, he experienced daily fear and stress; he participated in patrols searching for unexploded mortars, and he performed guard duty at night. He stated that he still has flashbacks from his time in Pleiku. Yet, the examiner reported, “No stressor reported.” The examiner noted that that she reviewed the claims file, yet at the same time, she reported that she reviewed only the DD 214, the Reports of Medical Examination and Medical History and noted, “No other records provided for review.” When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. The Board requires a VA examination and opinion regarding the Veteran’s psychiatric condition and its relationship to his time in the service, if any. 2. Service connection for hypertension (HTN) is remanded. The Veteran asserts that his diagnosed hypertension is due to his time in service, and in the alternative, is a result of his diagnosed psychiatric condition. He wrote in his Notice of Disagreement that he was diagnosed with HTN soon after leaving the service in Mexico and was prescribed medication and diet for his HTN. In addition, he has asked that VA obtain his “’legacy medical records from 1970s – 2000s’ from the South Texas Veterans Health Care System, outsourced facilities under VA contracts.” To date, his records have not been obtained, nor has he been afforded a VA examination to determine the connection between his HTN and his time in service or his psychiatric condition, if any. The Board requires a VA examination and medical opinion to address the Veteran’s claim for direct service connection for his HTN, as well as secondary to his diagnosed psychiatric condition. The matters are REMANDED for the following action: 1. After records development is completed, to include all VA treatment records in the South Texas Veterans Health Care System, the Veteran should be afforded a VA Mental Health examination to determine the nature of any acquired psychiatric disability, to include anxiety, depression, and PTSD. The examiner should elicit a full history from the Veteran and consider the lay statements of record. It is noted that the Veteran is competent to attest to factual matters of which he has first-hand knowledge. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. Following review of the entire claims file and examination of the Veteran, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that any current acquired psychiatric disability is related to an in-service injury, event, or disease, to include rocket attacks at Pleiku and the Veteran’s statement of daily stress and fear because of the daily incoming rockets, patrolling for unexploded ordnance, and perimeter guard duty at night. A rationale for all opinions expressed should be provided. 2. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any hypertension (HTN). The examiner should elicit a full history from the Veteran and consider the lay statements of record. It is noted that the Veteran is competent to attest to factual matters of which he has first-hand knowledge. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. Following review of the claims file and examination of the Veteran, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that any HTN disability is related to an in-service injury, event, or disease. The examiner must also provide an opinion as to whether it is at least as likely as not that the Veteran’s HTN is (1) proximately due to a service-connected disability, or (2) aggravated beyond its natural progression by a service-connected disability, particularly any acquired psychiatric disability. A rationale for all opinions expressed should be provided. (Continued on the next page)   3. Then, the record should again be reviewed. If any benefit sought on appeal remains denied, the Veteran and his representative should be furnished with a supplemental statement of the case and be given the opportunity to respond. T. REYNOLDS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD L. Nelson, Associate Counsel