Citation Nr: 18112705 Decision Date: 06/21/18 Archive Date: 06/20/18 DOCKET NO. 08-02 404 DATE: June 21, 2018 REMANDED Entitlement to service connection for hypertension, to include as secondary to service-connected disability, is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. REASONS FOR REMAND The Veteran had active military service from April 1970 to October 1973. These matters come before the Board of Veterans’ Appeals (Board) from May 2010 and November 2010 rating decisions of the Department of Veterans Affairs (VA), Regional Office (RO) in New Orleans, Louisiana. In January 2016, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge. A transcript of that hearing is of record. These matters were most recently before the Board in October 2016 when they were remanded for a clinical opinion on the issue of hypertension and because the issue of entitlement to a TDIU was intertwined with the issue of entitlement to service connection for hypertension. 1. Entitlement to service connection for hypertension, to include as secondary to service-connected disability is remanded. The Board finds that a supplemental opinion on the issue of whether the Veteran’s hypertension is as likely as not (50 percent or greater) caused by, or aggravated by, the Veteran’s posttraumatic stress disorder (PTSD) is warranted. The January 2017 VA clinician did not discuss aggravation; thus a remand for an opinion as to such is warranted. (The clinician also noted an onset date of 2003 for hypertension which is not the earliest notation of elevated blood pressure). In addition, in April 2017 correspondence, the Veteran’s attorney, in support of the Veteran’s contention, cited to a study by the National Institute of Health; thus, the VA clinician may wish to consider this literature. Several records contemporaneous to National Guard service reflect that the Veteran denied high blood pressure and they reflect various blood pressure readings without any notations that they are indicative of hypertension (e.g. September 1973, May 1976, May 1980, January 1982, July 1982, August 1982, May 1984). The earliest VA clinical records associated with the claims file are from 2002; however, a 2003 VA examination report reflects that a history of hypertension for 10 years, and a 2002 VA record’s “active problem ” list notes hypertension with a date of October 8, 1996. VA records earlier than 2002 may be useful to the clinician in determining the progress of the Veteran’s hypertension, and should be associated with the claims file. The Veteran’s hypertension has been noted to be in varying degrees of control. For example, it was noted to be in fair control (August 2002), well controlled (September 2002), uncontrolled (December 2003), in need of better control (November 2006), and in control or good control (February 2005, January 2007). A May 2005 VA clinical record notes that HCTZ 12.5 MG tab would be added and the Veteran was advised to increase the dosage if his blood pressure stayed elevated. The Veteran had strokes and/or transient ischemic attacks between approximately 2003 and 2007. The Veteran’s PTSD severity has been described as causing him to have symptoms such as being sad all the time, moderate to severe anxiety, and aggressive obsessions and causing total occupational impairment (April 2012 private Liss and Associates record) but also noted to have only mild or transient symptoms (January 2011 and July 2012 VA examination reports). He has also been noted to not be depressed, to have good sleep, and he felt that his mental health treatment was beneficial (the Veteran was taking Paxil) (March 2004, April 2007, and November 2007 VA clinical records). He has been noted to not have anger or crying spells (November 7, 2007 VA clinical record), and had a negative PTSD screening (December 28, 2017 VA clinical record). An April 2016 PTSD VA examination report (DBQ) reflects that his symptoms would only cause occupational and social impairment with reduced reliability and productivity. 2. Entitlement to a total disability rating based on individual unemployability due to service-connected disability is remanded. A decision on the remanded issue of entitlement to service connection for hypertension could significantly impact a decision on the issue of entitlement to a TDIU; therefore, the issues are inextricably intertwined. A remand of the claim for entitlement to a TDIU is required. The matters are REMANDED for the following action: 1. Obtain the Veteran’s VA treatment records for the period from January 1, 1993 to present (with the exception of those records already associated with the claims file) for his hypertension and PTSD. 2. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s hypertension is at least as likely as not (50 percent or greater) caused by or aggravated beyond its natural progression by his PTSD. The clinician should consider the pertinent evidence of record to include the following, if relevant: a.) the Veteran’s varying degree of hypertension and its control (i.e. fair control (August 2002), well controlled (September 2002), uncontrolled (December 2003), increased medication (May 2005), in need of better control (November 2006), in control or good control (February 2005, January 2007); b.) the Veteran had strokes and/or transient ischemic attacks between approximately 2003 and 2007; c.) the Veteran’s PTSD severity which has been described as causing him to have symptoms such as being sad all the time, moderate to severe anxiety, and aggressive obsessions (April 2012 private Liss and Associates record) but also noted to have only mild or transient symptoms (January 2011 and July 2012 VA examination reports), not cause him to be depressed, allowed for good sleep, and he felt that his mental health treatment was beneficial (the Veteran was taking Paxil) (see March 2004, April 2007, and November 2007 VA clinical records), not have anger or crying spells (November 7, 2007 VA clinical record), negative PTSD screening (December 28, 2017 VA clinical record), and have symptoms best summarized as only causing occupational and social impairment with reduced reliability and productivity (April 2016 VA DBQ); and d.) an article by the National Institute of Health at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3141329/. If the clinician finds that it is at least as likely as not that the Veteran’s hypertension is aggravated by his PTSD, and/or medication for PTSD, the clinician should identify, to the extent reasonably possible, the degree of additional disability resulting from such aggravation, indicating the “baseline” severity of such disability prior to any aggravation by the PTSD and the level of severity existing after the aggravation occurred. If the clinician cannot render an adequate opinion without an examination, schedule the Veteran for an examination. M.C. GRAHAM Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD T. Wishard