Citation Nr: 18157724 Decision Date: 12/13/18 Archive Date: 12/13/18 DOCKET NO. 17-00 211 DATE: December 13, 2018 REMANDED The claim of entitlement to service connection for hypertension is remanded. The claim of entitlement to service connection for a heart disability, to include coronary artery disease is remanded. The claim of entitlement to service connection for kidney disease is remanded. REASONS FOR REMAND The Veteran had honorable active duty service with the United States Navy from November 1972 to October 1978. 1. The claim of entitlement to service connection for hypertension is remanded. The Board cannot make a fully informed decision regarding the Veteran’s claim of entitlement to service connection for hypertension as a VA examination is not of record. The Veteran reported that, during his October 1978 separation examination, the nurse required him to lay down for approximately one hour to lower his blood pressure before taking a reading. At the time, his blood pressure measured as 138/102. The Veteran also stated that he received medication for hypertension around the time of his discharge from Audie Murphy VA Medical Center in conjunction with a dental procedure. The Veteran’s treating physician endorsed a long history of hypertension extending to the early 1980’s, as well as a history of idiopathic thrombocytopenic purpura, which eventually lead to a splenectomy in 1996. The Veteran presented to this physician in July 2006 with hematuria and proteinuria, which had been present for several years. Other VA Medical Center treatment records note referrals for proteinuria and hematuria in July 1999, and a “long history” of high blood pressure as high as 220/130. In March 2013, hypertension, hyperparathyroidism and dyslipidemia were all noted to be complications of the Veteran’s chronic kidney disease. While a deferred rating from February 2017 indicated that records needed to be requested from Audie Murphy VA Hospital, the record does not reflect if such a search occurred. Two other VA hospitals have been associated with the claims file. Furthermore, the Veteran is competent to report a diagnosis of hypertension made by VA medical professionals around the time of his separation. The Veteran’s current treating physician stated that his hypertension is “undoubtedly a contributing factor” to his present health condition, to include present diagnoses of hypertension, chronic kidney disease stage 3, and coronary artery disease. The Veteran’s reports of ongoing symptomatology following service, in conjunction with his reported diagnosis, provide at least an indication that his claimed conditions may be primarily or secondarily related to active duty service. As such, examinations are necessary on remand in order to determine their etiologies. See McLendon v. Nicholson, 20 Vet. App. 79, 82-3 (2006). 2. The claim of entitlement to service connection for a heart disability, to include coronary artery disease is remanded. See argument in section 1. 3. The claim of entitlement to service connection for kidney disease is remanded. See argument in section 1. The matters are REMANDED for the following action: 1. Contact the Veteran and the representative of record in order to identify any outstanding non-VA treatment records regarding the issues on appeal. If non-VA providers are identified, obtain releases for those records. Make all reasonable attempts to obtain the non-VA treatment records and associate them with the claims file. If such records cannot be obtained, inform the Veteran and the representative of record, and afford an opportunity to provide these outstanding records. 2. Obtain any relevant, outstanding VA treatment records that are not already associated with the claims file, to include any and all records at Audie Murphy VA Hospital in San Antonio, Texas. If no records are available, the claims folder must indicate this fact and the Veteran should be notified in accordance with 38 C.F.R. § 3.159 (e). All attempts to contact the Veteran should be documented in the record. 3. Once the aforementioned evidentiary development is complete, schedule the Veteran for a VA examination to assess the nature and etiology of his hypertension. The examiner must review the entire claims file, including a copy of this remand. The examiner must consider the Veteran’s lay reports of observable symptomatology, as well as the previously reported diagnosis of hypertension following his discharge from service. After a thorough review of the record is complete, the examiner must respond to the following: (a.) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s hypertension had its onset during active duty service, is related to an incident of service, or began within one year after discharge from active service. (b.) If not, is it at least as likely as not (50 percent or greater probability) that the Veteran’s hypertension was caused by or aggravated (increased in severity beyond its natural progression) by his diagnosed heart disability or chronic kidney disease? (c.) If aggravation of the hypertension is found to have occurred as a result of a service-connected disability, state if there is medical evidence created prior to the aggravation, or at any time between the onset of aggravation and the current level of disability that shows a baseline for the hypertension prior to aggravation. Note: The term “aggravation” in the above context refers to a permanent worsening of the underlying condition, as contrasted to temporary or intermittent flare-ups of symptomatology which resolve with return to the baseline level of disability. The examination report should specifically state that a review of the record was conducted. The examiner should provide a complete rationale for all opinions provided. If an opinion cannot be provided without to resorting to mere speculation, the examiner should identify all medical and lay evidence considered in this conclusion, fully explain why this is the case and identify what additional evidence (if any) would allow for a more definitive opinion. 4. Once the aforementioned evidentiary development is complete, schedule the Veteran for a VA examination to assess the nature and etiology of his chronic kidney disease. The examiner must review the entire claims file, including a copy of this remand. The examiner should take a thorough history from the Veteran. After a thorough review of the record is complete, the examiner must respond to the following: (a.) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s chronic kidney disease had its onset during active duty service, is related to an incident of service, or began within one year after discharge from active service. (b.) If not, is it at least as likely as not (50 percent or greater probability) that the Veteran’s chronic kidney disease was caused by or aggravated (increased in severity beyond its natural progression) by his diagnosed heart disability or hypertension? (c.) If aggravation of the chronic kidney disease is found to have occurred as a result of a service-connected disability, state if there is medical evidence created prior to the aggravation, or at any time between the onset of aggravation and the current level of disability that shows a baseline for the chronic kidney disease prior to aggravation. Note: The term “aggravation” in the above context refers to a permanent worsening of the underlying condition, as contrasted to temporary or intermittent flare-ups of symptomatology which resolve with return to the baseline level of disability. The examination report should specifically state that a review of the record was conducted. The examiner should provide a complete rationale for all opinions provided. If an opinion cannot be provided without to resorting to mere speculation, the examiner should identify all medical and lay evidence considered in this conclusion, fully explain why this is the case and identify what additional evidence (if any) would allow for a more definitive opinion. 5. Once the aforementioned evidentiary development is complete, schedule the Veteran for a VA examination to assess the nature and etiology of his heart disability. The examiner must review the entire claims file, including a copy of this remand. The examiner should take a thorough history from the Veteran. After a thorough review of the record is complete, the examiner must respond to the following: (a.) Identify any and all diagnoses pertaining to the Veteran’s heart; (b.) For each identified diagnosis, is it at least as likely as not (50 percent or greater probability) that the Veteran’s identified diagnosis had its onset during active duty service, is related to an incident of service, or began within one year after discharge from active service. (c.) If not, is it at least as likely as not (50 percent or greater probability) that the Veteran’s identified diagnosis was caused by or aggravated (increased in severity beyond its natural progression) by his hypertension or chronic kidney disease? (d.) If aggravation of the identified heart condition is found to have occurred as a result of a service-connected disability, state if there is medical evidence created prior to the aggravation, or at any time between the onset of aggravation and the current level of disability that shows a baseline for the heart condition prior to aggravation. Note: The term “aggravation” in the above context refers to a permanent worsening of the underlying condition, as contrasted to temporary or intermittent flare-ups of symptomatology which resolve with return to the baseline level of disability. The examination report should specifically state that a review of the record was conducted. The examiner should provide a complete rationale for all opinions provided. If an opinion cannot be provided without to resorting to mere speculation, the examiner should identify all medical and lay evidence considered in this conclusion, fully explain why this is the case and identify what additional evidence (if any) would allow for a more definitive opinion. 6. Following completion of the foregoing, the AOJ should review the record and readjudicate the claims on appeal. If any remain denied, the AOJ should issue an appropriate supplemental SOC, afford the Veteran and his representative an opportunity to respond, and return the case to the Board. B. MULLINS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD H. Fisher, Associate Counsel