Citation Nr: 20069167 Decision Date: 10/26/20 Archive Date: 10/26/20 DOCKET NO. 17-61 965 DATE: October 26, 2020 REMANDED Entitlement to service connection for hypertension is remanded. Entitlement to service connection for cerebral hemorrhage, to include as secondary to hypertension, is remanded. Entitlement to service connection for a mental health condition [claimed as posttraumatic stress disorder (PTSD) and anxiety disorder] is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1966 to June 1971. As an initial matter, the Board notes that the October 2017 statement of the case (SOC), after which the Veteran filed an appeal to the Board, also included the issues of entitlement to service connection for coronary artery disease and for multiple myeloma. However, in a September 10, 2019, statement, prior to the promulgation of a decision in this appeal, the Veteran’s representative expressly stated that the Veteran wished to withdraw his appeal of the claim for entitlement to service connection for coronary artery disease. In a July 2020 letter, the Veteran was notified that action on this appeal was discontinued. As such, this issue is no longer on appeal before the Board. With regard to the Veteran’s multiple myeloma, he was granted service connection for this disability in a June 2020 rating decision. This decision was a complete grant of benefits with respect to the issue of service connection pertaining to multiple myeloma, and the issue is no longer on appeal before the Board. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997). 1. Entitlement to service connection for hypertension is remanded. The Veteran is seeking entitlement to service connection for hypertension. Specifically, the Veteran asserted in a September 2019 statement that, by June 1972, he noticed that his blood pressure was continuously high. He reported that his diastolic reading would normally be 100 or higher until he suffered a stroke in 1996. He reported that he was working as a primary care physician in the Seattle area when he realized that his blood pressure was high. Because he was very busy working with his patients, he self-treated with a medication called Lopressor. He also tried acupuncture. He reported that he believes that his blood pressure was uncontrolled during service. He also reported that his diastolic blood pressure readings during service were 80 and above, which he asserted is hypertensive. In a September 2019 statement from the Veteran’s representative, it was also suggested that the Veteran’s high blood pressure could be linked to extreme stress and anxiety in service. A review of his service treatment records reveals the following blood pressure readings throughout service: 120/80, 118/82, 130/80, and 128/80. In light of the Veteran’s assertions that, as a physician, he was self-treating his high blood pressure dating back 1972 and his assertions that his repeated diastolic blood pressure of 80 or more during service should be considered elevated, the Board finds that this claim should be remanded in order schedule the Veteran for an appropriate VA examination determining the etiology of his hypertension. Furthermore, in March 2020, VA conceded the Veteran had exposure to Agent Orange based on his service on a Naval ship off the coast of Vietnam. In November 2018, the National Academy of Science (NAS) released an update to the report "Veterans and Agent Orange" wherein hypertension was upgraded from its previous classification in the category of "limited or suggestive" evidence of an association to herbicide agents, to the category of "sufficient" evidence of an association to herbicide agents. According to the NAS, "[t]he sufficient category indicates that there is enough epidemiologic evidence to conclude that there is a positive association" between hypertension and herbicide agent exposure. The Board declines to take judicial notice of the findings and conclusions found in the 2018 update to the NAS report, as this literature does not include facts of universal notoriety that are not subject to reasonable dispute. Monzingo v. Shinseki, 22 Vet. App. 97, 103 (2012). However, the Board will take judicial notice that the 2018 update to the NAS report "Veteran and Agent Orange" exists and finds that a VA examination and medical opinion by an appropriate VA examiner to consider this report in relationship to the Veteran's medical history is appropriate. 2. Entitlement to service connection for cerebral hemorrhage, to include as secondary to hypertension, is remanded. The Veteran has asserted that he suffered hemorrhagic strokes in 1996 and 2016, which left him with significant residuals and that his treating physician has related his strokes to his hypertension. See Representative’s statement, September 2019. Moreover, in his May 2017 claim, the Veteran asserted that his cerebral hemorrhage is secondary to anxiety. As the issue of entitlement to cerebral hemorrhage can be impacted by resolution of the Veteran’s hypertension claim being remanded, the Board finds that the issue of entitlement to cerebral hemorrhage must be remanded as well. Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two or more issues are inextricably intertwined if one claim could have significant impact on the other). Upon remand, the Board finds that a medical opinion should be obtained on this matter addressing whether the Veteran’s cerebral hemorrhage was caused or aggravated by his hypertension. 3. Entitlement to service connection for a mental health condition [claimed as PTSD and anxiety disorder] is remanded. The Veteran is seeking service connection for a mental health condition related to his active duty service. In a June 2017 statement, the Veteran asserted that he received no introduction to the military or military training at any time prior to receiving orders to assume the position of sole medical officer on the USS Sacramento. He reported that, within 30 minutes of receiving these orders, he presented himself to the psychiatric clinic at the Naval Hospital and saw Dr. Osterwhich. He reported that he continued to see the Navy psychiatrist throughout the rest of his internship until July 1968, when he reported to the USS Sacramento and was shipped out to the Republic of Vietnam. The Veteran reported constant bullying and mean-spirited teasing throughout his Naval career. He reported the atmosphere on the USS Sacramento to be extremely hostile and that he was the subject of numerous hazing incidents. He reported being awoken several times in the middle of the nights and ordered by the “XO” to accompany patients by helicopter to adjacent carriers. He reported that he feared for his life during these dangerous carrier landings. He later learned that these false and life-threatening commands were fabricated. He asserted he was falsely told that his duties onboard the USS Sacramento would be prolonged just days before his replacement was due to arrive. He reported going ashore in Singapore for 2 days with officers, who he believed to be his friends, but that they returned to the ship without him, causing him to nearly miss the ship. He reported that a young sailor that he had treated just days before was murdered, and he had to identify the body. He reported he was forced to perform amputations and treat severe injuries that were well out of the range of his experience. In a separate June 2017 statement, the Veteran asserted that he experienced continual stress and harassment during service. He reported that he accompanied patients by helicopters at night and landed on adjacent carriers in rough waters in approximately August and September 1968. He also reported an incident while docking at an ammunition pier in Subic Bay in about February to May 1969. The USS Sacramento was approaching at too high of a speed and the order “all hands brace” was given. His vessel missed the pier by inches. A collision could have resulted in a significant explosion and possible loss of life. He also reported that his personal trauma incidents included a false report in July 1969 that his duty aboard the USS Sacramento would be extended. He was abandoned by his fellow sailors in Singapore in the Spring of 1969. He reported the death of a service member in July or August of 1969, which was disturbing to him since he had recently performed surgery on the servicemember. (He clarified that he was asked to identify the servicemember but did not actually identify him.) He also reported that he was “severely dressed down by the XO” in front of other department heads as a result of not receiving naval training in July or August 1968. In support of his claim, the Veteran has submitted a June 2017 letter from a private licensed mental health counselor. This counselor reported that he has known the Veteran socially for over 10 years. He indicated that, while not producing a formal diagnosis, his observations indicate a strong likelihood of PTSD. He reported that the Veteran has recounted to him persistent nightmares that place him back on the USS Sacramento. He concluded that he could strongly attest that the Veteran suffers with many of the symptoms of PTSD. The Veteran also submitted a June 2017 letter from a licensed mental health counselor at Magnolia Psychological Services, who treated the Veteran from August 1998 to November 2016 with periodic interruptions for adjustment disorder and general anxiety disorder. This counselor noted that the Veteran was subject to harassment, bullying, threats and pressuring from crewman that led to symptoms consistent with PTSD. As an initial matter, the Board notes that the June 2017 letter from the counselor at Magnolia Psychological Services reflects that the Veteran has received mental health treatment periodically for 18 years. The Veteran also states he has seen many mental health professionals since his service. Attempts should be made to obtain all outstanding, pertinent private and VA treatment records. Further, in light of the Veteran’s assertions that he was seen at the psychiatric clinic at the Naval Hospital by Dr. Osterwhich throughout his internship until July 1968, the Board finds that efforts should be made to obtain these identified records directly from the medical facility. Finally, in light of the letter from Magnolia Psychological Services, the Board finds that the Veteran should be scheduled for a VA examination to diagnose him with all current psychiatric disabilities and to provide an etiological opinion regarding any diagnosed disabilities. The matters are REMANDED for the following action: 1. Associate with the claims file all outstanding treatment records from the VA Puget Sound Health Care System (and associated outpatient clinics) from January 2020 to the present. 2. Request that the National Personnel Records Center search for mental health treatment records from the Naval Hospital in San Diego, California, dated between June 1968 and July 1968. If the NPRC cannot locate records, make a request to the Naval Hospital in San Diego. If neither request results in the records being received, advise the Veteran of such and give him an opportunity to submit any records he may have. 3. Send to the Veteran a letter requesting that he provide sufficient authorization to enable the RO to obtain any outstanding, pertinent private medical records, to specifically include all mental health records and all available records from Magnolia Psychological Services from 1998 to 2016. Request all identified records. Associate any records received, including negative responses, with the claims file. 4. Schedule the Veteran for a VA examination to address his hypertension claim. The examiner should review the claims file, conduct any necessary tests and studies, and elicit a complete history from the Veteran. All findings should be reported in detail. The examiner should determine whether the Veteran has hypertension. If so, the examiner should render an opinion as to whether it is at least as likely as not that diagnosed hypertension began during, or was caused by, his active duty service, to include his reports of stress during his active duty service and/or herbicide exposure. The examiner should consider and discuss the following: (a) the NAS 2018 update to the report "Veterans and Agent Orange" wherein hypertension was upgraded from its previous classification in the category of "limited or suggestive" evidence of an association to herbicide agents, to the category of "sufficient" evidence of an association to herbicide agents; and (b) the Veteran’s assertions that his repeated diastolic blood pressure of 80 or more during service should be considered elevated. The examiner must provide the underlying reasons for any opinions provided. 5. Schedule the Veteran for a VA examination to address his cerebral hemorrhage claim. The examiner should review the claims file, conduct any necessary tests and studies, and elicit a complete history from the Veteran. All findings should be reported in detail. The examiner should determine whether the Veteran has any current residuals of his cerebral hemorrhage. If so, the examiner should render an opinion as to whether it is at least as likely as not that the Veteran’s cerebral hemorrhage was caused by his active duty, to include his reported in-service stress. The examiner should also render an opinion as to whether it is at least as likely as not that the Veteran’s cerebral hemorrhage was caused or aggravated by his hypertension or by an anxiety or psychiatric disorder of any kind. The examiner must provide the underlying reasons for any opinions provided. 6. Schedule the Veteran for a VA examination to address his mental health condition claim. DO NOT SCHEDULE THE EXAM UNTIL RECORDS ARE OBTAINED PURSUANT TO INSTRUCTIONS 2 AND 3 ABOVE, OR IT IS DETERMINED SUCH RECORDS DO NOT EXIST. The examiner should review the claims file, conduct any necessary tests and studies, and elicit a complete history from the Veteran. All findings should be reported in detail. Then, the examiner should diagnose the Veteran with all current psychiatric disabilities, to include PTSD or an anxiety disorder. The examiner should then render an opinion as to whether it is at least as likely as not that diagnosed psychiatric disability, to include PTSD or an anxiety disorder, began during, or was caused by, his active duty service. The examiner must provide the underlying reasons for any opinions provided. MICHELLE L. KANE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board L. Durham, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.