Citation Nr: 18152726 Decision Date: 11/26/18 Archive Date: 11/23/18 DOCKET NO. 15-46 253 DATE: November 26, 2018 REMANDED 1. Entitlement to service connection for gout, to include as secondary to service-connected left knee patellofemoral pain syndrome, is remanded. 2. Entitlement to service connection for hypertension, to include as secondary to service-connected posttraumatic stress disorder (PTSD), is remanded. 3. Entitlement to a rating in excess of 30 percent for PTSD is remanded. REASONS FOR REMAND The appellant is a Veteran who served on active duty from February 1988 to November 1993. These matters are before the Board on appeal from July 2014 and December 2015 rating decisions. 1. Entitlement to service connection for gout, to include as secondary to left knee patellofemoral pain syndrome. At a November 2015 AOJ hearing, the Veteran testified that he first received a diagnosis of gout (by Dr. Malloy of CareSouth) shortly after he was discharged from service, and that his first flare-up occurred in approximately February 1994. A review of the claims file found that records from that provider apparently have not been sought. A remand to obtain such private treatment records is necessary. Additionally, on July 2014 VA examination, the examiner opined that the Veteran’s gout is less likely than not (less than 50% probability) proximately due to or the result of the Veteran’s service-connected left knee condition. The examiner opined that it is less likely than not (less than 50%) that the Veteran’s service-connected knee patellofemoral syndrome has caused or contributed in any way to his gout. The examiner opined that this is evidenced by these disease processes being distinct entities, which is congruent with the medical literature. In a July 2014 addendum opinion, the reviewing provider opined that the Veteran’s gout is a diagnosable disease with clear and specific etiologies; it is not an unknown diagnosis. The reviewing provider opined that the causation is clear (elevated uric acid), this is a diagnosable disease, and it has nothing to do with any environmental exposures incurred while in service in Southwest Asia. The Board cannot make a fully-informed decision on the issue of service connection for gout because no VA examiner has provided an adequate opinion regarding whether the Veteran’s gout was aggravated by his service-connected left knee disability. Additional medical guidance is necessary. 2. Entitlement to service connection for hypertension, to include as secondary to PTSD, is remanded. At a November 2015 AOJ hearing, the Veteran testified that he first had a problem with high blood pressure shortly after his discharge from service, when medication was prescribed. He testified that his doctor indicated there may be a relationship between his PTSD and his hypertension. A review of the claims file, found that the records pertaining to such treatment are not in evidence. A remand to obtain them is necessary. Additionally, on December 2015 VA record review and opinion, the reviewing provider opined that it cannot be generalized that PTSD causes hypertension. The reviewing provider opined that there is simply not enough evidence that PTSD has a causal link to hypertension and, therefore, it is less likely as not that the Veteran’s current hypertension is related to his PTSD; rather, it is more likely to be idiopathic or essential in etiology. The Board cannot make a fully-informed decision on the issue of service connection for hypertension because no VA examiner has opined whether the Veteran’s hypertension was incurred in or caused by service, or manifested to a compensable degree within one year of his separation from service, or aggravated by his service-connected PTSD. Additional medical guidance is necessary. 3. Entitlement to a rating in excess of 30 percent for PTSD is remanded. The Veteran contends that his PTSD has increased in severity since he was last examined by VA in October 2015. A March 2017 statement by his treating VA therapist notes that his treatment plan focuses on modifying excessive negative appraisals, correcting autobiographical memory disturbance, and removing problematic behavioral/cognitive strategies. The Veteran also submitted a treatment record indicating that he sought emergency room treatment for anxiety and insomnia in August 2017. Given the length of the intervening period since he was last examined and the suggestion of worsening since, a contemporaneous examination to assess the disability is necessary. The record reflects that there may be outstanding pertinent VA treatment records. Any such records are constructively of record, and must be secured. The matters are REMANDED for the following action: 1. Secure for the record the complete updated (from June 2018 to the present) records of VA treatment the Veteran has received for the disabilities on appeal. 2. Ask the Veteran to complete VA Forms 21-4142 for all private providers of treatment he has received for gout and hypertension, in particular Dr. Malloy and/or CareSouth. Obtain such records. 3. After the treatment records are received, arrange for the Veteran to be examined by an appropriate VA clinician to determine the etiology of his gout and hypertension. The Veteran’s record (to include this remand) must be reviewed by the examiner in conjunction with the examination. On a review of the record and evaluation/interview of the Veteran, the examiner should respond to the following: (a.) Identify the likely etiology for the Veteran’s gout and hypertension. For each disability, opine whether it is at least as likely as not (a 50% or better probability) that such disability (1) began during the Veteran’s active service, (2) was manifested (to a compensable degree) within one year after discharge from service, (3) was noted during service with continuity of symptoms since, or (4) is otherwise etiologically related to service. (b.) Opine whether it is at least as likely as not (a 50% or better probability) that the Veteran’s gout was (1) caused by or (2) aggravated by, his service-connected left knee disability. The opinion must address aggravation. (c.) Opine whether it is at least as likely as not (a 50% or better probability) that the Veteran’s hypertension was (1) caused by or (2) aggravated by, his service-connected PTSD. The opinion must address aggravation. The examiner must include rationale with all opinions. 4. Also arrange for a psychiatric evaluation of the Veteran to assess the severity of his PTSD. The examiner should review the Veteran’s claims file in conjunction with the examination, and should have available for review the schedular criteria for rating mental disorders. The examiner should describe in detail all signs and symptoms of the disability (noting the presence or absence of all symptoms listed in the schedular criteria for psychiatric ratings above 30 percent, as well as any symptoms of such nature and severity found that are not listed in the schedular criteria) GEORGE R. SENYK Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD D. Schechner, Counsel