Citation Nr: 18161204 Decision Date: 12/31/18 Archive Date: 12/28/18 DOCKET NO. 15-22 967 DATE: December 31, 2018 REMANDED Entitlement to service connection for alcoholism, to include as secondary to depression is remanded. Entitlement to service connection for depression, to include as secondary to service-connected hypertension is remanded. Entitlement to service connection for gout, to include as secondary to service-connected hypertension, is remanded REASONS FOR REMAND 1. Entitlement to service connection for gout, to include as secondary to service-connected hypertension, is remanded In an August 2012 VA knee and lower leg examination, the examiner noted that the Veteran was first diagnosed with gout in 1992, but ultimately opined that the Veteran’s gout was less likely than not caused by or related to his service-connected hypertension. In support of that opinion, the examiner commented that while diuretics have been associated with attacks of gout, low doses of hydrochlorothiaride did not seem to increase the risk of attacks of gout, and further stated that the Veteran was not taking a diuretic for his hypertension. However, the Board notes that the Veteran previously underwent a November 2011 VA examination for hypertension, in which the examiner noted that the Veteran developed hypertension while in service in 1981 or 1982, and was prescribed hydrochlorothiaride and continued medication since that time, developing complications of atrial fibrillation in 2005. In a subsequent July 2014 VA examination for hypertension, the examiner noted that the Veteran was treated with daily hydrochlorothiaride in service, and that after separation, he had his anti-hypertensive regimen revised by Kaiser physicians, and had it further revised in 2005 after his atrial fibrillation. While the August 2012 examiner did note that low doses of hydrochlorothiaride did not seem to increase the risk of attacks of gout, the examiner does not discuss the Veteran’s past treatment for hypertension with daily hydrochlorothiaride, whether such could be considered a low dose, or whether his past use of that medication could be related to his current gout. Because the August 2012 VA examination did not address all the relevant evidence of record, a remand is therefore required to obtain a new VA examination to address the nature and etiology of the Veteran’s gout. See Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007) (holding that once VA undertakes the effort to provide an examination when developing a claim, even if not statutorily obligated to do so, VA must ensure that the examination provided is adequate). Additionally, the Board notes that while the August 2012 VA examination noted that the Veteran’s initial diagnosis and treatment for gout occurred in 1992, those medical records do not appear to have been associated with the claims file. Thus, it appears there are outstanding private or VA treatment records, and such should be obtained on remand along with any other outstanding private or VA treatment records. 2. Entitlement to service connection for depression, to include as secondary to service-connected hypertension is remanded. In a May 2014 statement, the Veteran indicated that his depression began when he found out he had hypertension in service. The Veteran underwent an April 2015 VA contract psychiatric examination, in which the examiner diagnosed the Veteran with unspecified depressive disorder and alcohol use disorder. The examiner noted that the Veteran claimed his depression began in the mid 1980’s, noting that he was having symptoms when he got out of service, which got worse over time. Ultimately, the examiner opined that the Veteran’s depression was less likely than not related to his service-connected hypertension, and more likely related to his use of alcohol, history of sleep apnea, and other stressors. However, the Board notes that the examiner’s etiology opinion did not address direct service connection with respect to the Veteran’s depression, despite the Veteran’s statements indicating that his depression began in service and that his symptoms have persisted and worsened since that time. As such, a remand is necessary to obtain a new VA psychiatric examination and opinions with respect to the Veteran’s depression. See Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007). 3. Entitlement to service connection for alcoholism, to include as secondary to depression is remanded. Finally, because a decision on the remanded issue of service connection for depression could significantly impact a decision on the issue of service connection for alcoholism, the issues are inextricably intertwined. A remand of the claim for service connection for alcoholism is required. The matters are REMANDED for the following action: 1. Obtain any outstanding VA treatment records from the Oceanside Community Based Outpatient Clinic, San Diego VA Medical Center, or any other VA medical facility that may have treated the Veteran, and associate those documents with the claims file. 2. After securing the necessary releases, attempt to obtain any outstanding private treatment records identified by the Veteran, to include records relating to his initial diagnosis and treatment for gout in 1992. If any identified records cannot be obtained and further attempts would be futile, such should be noted in the claims file and the Veteran should be notified so that he can attempt to obtain those records on his own behalf. 3. Schedule the Veteran for an examination with an appropriate specialist who has not previously participated in this case regarding his service connection claim for gout. Following review of the claims file and examination of the Veteran, the examiner should opine as to whether it is at least as likely as not (a degree of probability of 50 percent or higher) that the Veteran’s current gout is related to his military service. The examiner must also provide an opinion addressing whether the Veteran’s gout is at least as likely as not (50 percent probability or greater) proximately due to, or aggravated by, his service-connected hypertension disorder, to include any medications prescribed to treat his hypertension disorder. The examiner must address the relevant evidence of record, to include the medical evidence of record documenting treatment of the Veteran’s hypertension in service with hydrochlorothiaride. The opinion must address both causation and aggravation to be deemed adequate. The examiner is advised aggravation means an increase in the severity of the underlying disability beyond its natural progression. If aggravation is found, the examiner should attempt to quantify the degree of additional disability resulting from the aggravation. The examination report must include a complete rationale for the opinion provided. 4. Schedule the Veteran for a VA examination with an appropriate medical practitioner who has not previously participated in this case to determine if the Veteran currently meets or has met at any time during the appeal, the criteria for a diagnosis of an acquired psychiatric disorder, to specifically include depression. Following review of the claims file and examination of the Veteran, the examiner should identify all acquired psychiatric disorders currently found or found to have existed at any time during the course of this appeal, even if resolved at the time of examination. For each acquired psychiatric disorder diagnosed, the examiner should opine as to whether it is at least as likely as not (a degree of probability of 50 percent or higher) that the disability is related to the Veteran's military service. The examiner must also provide an opinion addressing whether the Veteran’s psychiatric disorder is at least as likely as not (50 percent probability or greater) proximately due to, or aggravated by, his service-connected hypertension disorder. The examiner must address the relevant evidence of record, to include the Veteran’s lay statements with respect to the onset of his symptomatology, including his May 2014 statement that he developed depression when he found out that he was hypertensive in service. The examiner may not disregard the Veteran’s lay statements as to onset of symptoms solely on the basis that they are not documented in the Veteran’s service treatment records. The opinion must address both causation and aggravation to be deemed adequate. The examiner is advised aggravation means an increase in the severity of the underlying disability beyond its natural progression. If aggravation is found, the examiner should attempt to quantify the degree of additional disability resulting from the aggravation. All findings must be reported in detail and all opinions must be accompanied by a clear rationale. M. HYLAND Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD B. Reed, Associate Counsel