Citation Nr: 18154865 Decision Date: 12/04/18 Archive Date: 11/30/18 DOCKET NO. 16-52 438 DATE: December 4, 2018 REMANDED Entitlement to service connection for a back disorder is remanded. Entitlement to service connection for hypertension, to include as secondary to service-connected polycystic ovarian syndrome (PCOS), is remanded. Entitlement to service connection for a psychiatric disorder, to include posttraumatic stress disorder (PTSD) and depression, is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1982 to August 1990. This case comes before the Board of Veterans’ Appeals (Board) on appeal from a July 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). 1. Service connection for a back disorder. The Veteran’s service treatment records from active duty reflect treatment for recurrent back pain. She did not undergo radiology or diagnostic imaging during service. Post-service treatment records reflect that she has been diagnosed with degenerative changes affecting intervertebral disc spaces with narrowing and multi-level degenerative disc disease. The Veteran has asserted that she lifted heavy equipment and that an injury occurred during her military service and that she has had numerous physical therapy appointments as a result of her chronic back pain since active duty. However, she has not been afforded a VA examination for in connection with the claim. Therefore, the Board finds that a VA examination and medical opinion are needed to determine the nature and etiology of any back disorder that may be present. See McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). 2. Service connection for hypertension. The Veteran has been diagnosed with hypertension. She was afforded VA examinations in August 2014 and April 2016, and a VA medical opinion was obtained in May 2016. In the May 2016 VA opinion, the examiner found that there was no relationship between pregnancy-induced hypertension in service and the Veteran’s current diagnosis of essential hypertension, while acknowledging that both disorders have many features in common and that the conditions and causes of each has yet to be clarified. Despite noting the Veteran was not diagnosed with hypertension until 1992, the examiner did not address several other instances of hypertensive episodes that occurred outside the timeframe of pregnancy during the Veteran’s active duty. Additionally, the Veteran has asserted that her hypertension is caused by her service-connected PCOS. Therefore, the Board finds an additional medical opinion is needed. 3. Service connection for a psychiatric disorder. The Veteran filed a claim for PTSD in October 2011. She has reported experiencing trauma when she suffered two pregnancy losses while on active duty, in 1988 and 1990, with the latter one being a near-death experience. The Veteran was afforded a VA examination in April 2016 in connection with her claim. The examiner diagnosed her with major depressive disorder (MDD), but PTSD was not diagnosed because there was no intrusive re-experiencing, avoidance of stimuli, or hyperarousal. The examiner opined that the Veteran’s psychiatric disorder is less likely than not related to service because, while her 1990 loss continues to be distressing, there is no evidence in the medical record to indicate that the event caused depression. Nevertheless, the April 2016 examiner did not address the Veteran’s assertion that she took leave following the event in service and subsequently withdrew her re-enlistment paperwork. The Veteran has stated that she did not discuss her negative feelings soon thereafter, that no counseling services were offered to her in the military, and that it has taken time to sort out her psychiatric state surrounding her reported stressors from service. The examiner also did not discuss the Veteran’s first miscarriage in 1988 during active duty or her reported symptoms of anxiety/panic attacks. See September 2016 statement. In addition, the April 2016 VA examiner did not acknowledge the treatment records pertaining to depression symptoms in 2001 and the 2004 prescription for depression medication (part of the basis for the April 2016 opinion was that the Veteran was not diagnosed with depression until 2011). For these reasons, the Board finds that an additional medical opinion is needed. The matters are REMANDED for the following action: 1. The Agency of Original Jurisdiction (AOJ) should request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for a back disorder, hypertension, and a psychiatric disorder. After acquiring this information and obtaining any necessary authorization, the RO should obtain and associate these records with the claims file. The AOJ should also obtain any outstanding VA medical records. 2. The AOJ should attempt to obtain any outstanding service personnel records, to include documentation pertaining to the Veteran’s reenlistment. The RO should document all efforts undertaken and the responses received. 3. After any additional records are associated with the claims file, the Veteran should be afforded a VA examination to determine the nature and etiology of any back disorder that may be present. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran’s service treatment records, post-service medical records, and assertions. The examiner should note that the Veteran is competent to attest to factual matters of which she has first-hand knowledge. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should state this with a fully reasoned explanation. The examiner should provide an opinion as to whether it is at least as likely as not that the Veteran has a current back disorder that manifested in or is otherwise causally or etiologically related to her military service, to include any injury or symptomatology therein. In rendering his or her opinion, the examiner should consider the Veteran’s September 2016 statement that she injured her back in service and carried heavy equipment. (The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of conclusion as it is to find against it.) A clear rationale for all opinions would be helpful, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 4. After obtaining any outstanding records, the Veteran should be afforded a VA examination to determine the nature and etiology of any hypertension. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran’s service treatment records, post-service medical records, assertions, and the American Journal of Cardiology article provided by the Veteran in September 2016. The examiner should note that the Veteran is competent to attest to factual matters of which she has first-hand knowledge. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should state this with a fully reasoned explanation. The examiner should provide an opinion as to whether it is at least as likely as not that the Veteran has hypertension that manifested in service or within one year thereafter or that is otherwise related thereto, to include the blood pressure readings documented in the service treatment records associated with the claims file in December 1987, August 1988, October 1988, and May 1989. The examiner should also state whether it is at least as likely as not that hypertension was either caused by or aggravated by the Veteran’s service-connected polycystic ovarian syndrome. (The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of a certain conclusion as it is to find against it.) A clear rationale for all opinions must be provided and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 5. After the foregoing development to obtain records has been completed, the Veteran should be afforded a VA examination to determine the nature and etiology of any psychiatric disorder that may be present. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran’s service treatment records, post-service medical records, and assertions, such as her January 2013 and September 2016 statements. The examiner should note that the Veteran is competent to attest to factual matters of which she has first-hand knowledge. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should state this with a fully reasoned explanation. The examiner should identify all current psychiatric disorders. If any previously diagnosed psychiatric disorders are not found on examination, the examiner should address whether they were misdiagnosed or have resolved. For each diagnosis identified other than PTSD, the examiner should provide an opinion as to whether it is at least as likely as not that the disorder manifested in or is otherwise causally or etiologically related to the Veteran’s military service. In rendering this opinion, he or she should address the Veteran’s contention that she did not seek psychiatric treatment soon after her traumatic experiences, but that she chose to leave active duty service because of the May 1990 ectopic pregnancy. With regards to PTSD, the AOJ should provide the examiner with a summary of any verified in-service stressors, and the examiner must be instructed that only these events may be considered for the purpose of determining whether exposure to an in-service stressor has resulted in PTSD. The Board notes that the Veteran has identified her stressors as pregnancy losses in 1988 and 1990, which are documented in the service treatment records. The examiner should determine whether the diagnostic criteria to support the diagnosis of PTSD have been satisfied. If the PTSD diagnosis is deemed appropriate, the examiner should then comment upon the link between the current symptomatology and any verified in-service stressor. (The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of conclusion as it is to find against it.) A clear rationale for all opinions must be provided and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. J.W. ZISSIMOS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD B. Kuczynski