Citation Nr: 1824315 Decision Date: 04/24/18 Archive Date: 05/03/18 DOCKET NO. 14-34 641 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUE Entitlement to service connection for hypertension, to include as secondary to service-connected posttraumatic stress disorder (PTSD). REPRESENTATION Veteran represented by: Military Order of the Purple Heart of the U.S.A. ATTORNEY FOR THE BOARD L. B. Yantz, Counsel INTRODUCTION The appellant is a Veteran who served on active duty from August 1964 to August 1967. This matter is before the Board of Veterans' Appeals (Board) on appeal from a July 2012 decision of a Department of Veterans Affairs (VA) Regional Office (RO). [The Veteran had also perfected an appeal of the denial of service connection for bilateral hearing loss. Thereafter, an October 2017 rating decision granted this claim in full by awarding service connection for bilateral hearing loss. Consequently, this matter is not before the Board.] The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the Veteran if action on his part is required. REMAND On review of the record, the Board has found that additional development is necessary for the claim on appeal. The Veteran contends that his current hypertension either is related to his military service or is secondary to his service-connected PTSD. The Veteran's service treatment records are silent for any complaints, findings, diagnosis, or treatment of hypertension. His service personnel records verify that he served in Vietnam in 1966 and 1967, and thus he is presumed to have been exposed to herbicide agents therein. 38 C.F.R. § 3.307(a)(6)(iii) (2017). Post-service, the medical evidence of record documents an initial diagnosis of hypertension for the Veteran in September 2000, as well as treatment for his hypertension throughout the period of claim from VA and private treatment providers. In a February 2012 private treatment record, the Veteran's private doctor provided the following speculative opinion: "Also had a long discussion about his [PTSD] and thinking that it may be the cause of his hypertension. There is a possibility that there could be an association based on studies, but unclear of its cause and effect for him. A lot of people without [PTSD] have hypertension, so unclear what the association would be for him." In June 2012, the Veteran underwent a VA hypertension examination and was diagnosed with essential hypertension. The VA examiner opined that the Veteran's essential hypertension was not permanently aggravated by his PTSD. For rationale, the VA examiner noted: "Temporary fluctuations/elevations of blood pressure from emotional [turbulence] that may result from PTSD is not a sustained condition and would not be considered a pathological process. [The Veteran's] age, obesity and deconditioning would influence hypertensive state more than his emotional fluctuations." In his September 2012 notice of disagreement, the Veteran stated that, during his visits to the Mount Vernon, Missouri VA Community Based Outpatient Clinic (CBOC), his doctor (Dr. Jones) "has said that my blood pressure is in relation to my PTSD....[he] put together that the blood pressure is [] secondary to my PTSD." The Board notes that the most recent [not audiology-related] VA treatment report of record from the Mount Vernon CBOC - part of the Veterans Health Care System of the Ozarks, based in Fayetteville, Arkansas - is dated in February 2011. [In June 2017, pursuant to a separate claim that is not on appeal, only his audiology-related VA treatment records from that facility, dating through May 2017, were associated with the claims file.] On remand, all VA treatment records must be obtained and associated with the claims file. In January 2015, the Veteran underwent another VA hypertension examination (conducted by the same VA examiner who conducted the June 2012 VA hypertension examination) and was again diagnosed with essential hypertension. The VA examiner opined that the Veteran's essential hypertension "is less likely as not (less than 50/50 probability) caused by, a result of or permanently aggravated by his PTSD symptoms." For rationale, the VA examiner noted: "There is no objective data to support [that] his PTSD caused or contributes to his essential hypertension. Any elevation in BP [blood pressure] secondary to PTSD sx [symptoms] [is] not pathological and would be transient." While the above-noted medical opinions addressed the question of whether the Veteran's hypertension was caused or is aggravated by his service-connected PTSD, the Board notes that there are no medical opinions currently of record which address whether there is any relationship between his hypertension and his presumed exposure to herbicide agents during his verified service in Vietnam. See Nat'l Acad. of Sci., Inst. of Med., Veterans & Agent Orange: Update 2014 (2016) (the National Academy of Sciences concluded that there was limited or suggestive evidence of an association between exposure to Agent Orange and hypertension). On remand, after all outstanding treatment records have been obtained, an addendum medical opinion is required to address this question. Accordingly, the case is REMANDED for the following actions: 1. With any needed assistance from the Veteran, including securing from him a VA Form 21-4142 (Authorization and Consent to Release Information to VA) for each identified provider, obtain all outstanding records of the Veteran's treatment for hypertension at any time since his discharge from service. If any identified records cannot be obtained and it is determined that further attempts would be futile, such should be noted in the claims file and the Veteran should be notified so that he can make an attempt to obtain those records on his own behalf. 2. Obtain and associate with the claims file all updated VA treatment records from February 2011 to the present, to specifically include from the Mount Vernon, Missouri VA CBOC. 3. After completing the development requested in items 1 and 2, forward the claims file, to include a copy of this remand, to a clinician with appropriate expertise for an addendum medical opinion as to the nature and etiology of the Veteran's current hypertension. The need for another examination is left to the discretion of the medical professional offering the addendum opinion. After reviewing the claims file, the reviewing clinician should provide an opinion on the following question: Is it at least as likely as not (50 percent probability or greater) that the Veteran's hypertension was related to or caused by his exposure to herbicide agents in service? The reviewing clinician should provide a complete rationale for any opinion provided. If the reviewing clinician cannot provide any requested opinion without resorting to speculation, he or she should expressly indicate this and provide a supporting rationale as to why an opinion cannot be made without resorting to speculation. 4. Thereafter, review the record, ensure that all development is completed (and arrange for any further development suggested by additional evidence received), and readjudicate the claim on appeal for entitlement to service connection for hypertension. If the benefit sought on appeal remains denied, in whole or in part, a supplemental statement of the case must be provided to the Veteran and his representative. After the Veteran and his representative have had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. § 5109B (2012). _________________________________________________ M. SORISIO Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C. § 7252 (2012), only a decision of the Board is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2017).