Citation Nr: 20021587 Decision Date: 03/26/20 Archive Date: 03/26/20 DOCKET NO. 16-06 514 DATE: March 26, 2020 REMANDED Entitlement to service connection for a right shoulder disability, to include as due to a chronic multisymptom illness is remanded. Entitlement to service connection for hypertension, to include as secondary to posttraumatic stress disorder (PTSD) and/or due to a chronic multisymptom illness is remanded. Entitlement to service connection for a migraine disability, to include as secondary to PTSD and/or due to a chronic multisymptom illness is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1999 to August 2003. The Board denied the matters on appeal in October 2018. The Veteran appealed the decision to the U.S. Court of Appeals for Veterans Claims (Court). In a September 2019 Joint Motion for Partial Remand (JMPR), the Court vacated October 2018 decision, in part, and remanded the current issues on appeal back to the Board for readjudication in accordance with the JMPR. The Veteran served in Southwest Asia during his active duty service. Although the Veteran’s DD-214 is negative for evidence of foreign service, the Veteran’s service treatment records (STRs) and personnel records show evidence of deployment to Kuwait and Iraq; and in a September 2007 Administrative Decision, VA conceded a PTSD stressor that occurred in Iraq. Based upon the Veteran’s confirmed service in Southwest Asia, the Board has recharacterized the Veteran’s service connection claims to include direct service connection based upon a chronic multisymptom illness. 38 C.F.R. § 3.317 The Board notes service connection for acid reflux was remanded by the Board in October 2018. Development has not been completed regarding the acid reflux claim, and therefore, the issue is not currently before the Board at this time. 1. Entitlement to service connection for a right shoulder disability, to include as due to a chronic multisymptom illness is remanded. The Veteran was provided a VA examination in March 2013. The examiner provided a negative nexus opinion, and in support of this opinion, the examiner stated the Veteran’s military records did not reveal “an acute injury of the right shoulder.” The Court has held that when VA provides a claimant with a medical examination, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). A medical examination is adequate when it is based on consideration of the Veteran’s relevant medial history and provides the Board with sufficient information to render a fully informed decision on the claim. See Ardison v. Brown, 6 Vet. App. 405, 407 (1994). The Board finds the March 2013 examination is inadequate, for the examiner failed to provide a rationale for his negative opinion, apart from noting the Veteran did not have an acute injury in service and did not have a shoulder disability in service. The examiner did not address the Veteran’s lay contentions provided during the examination, of in-service injury to his right shoulder. Additionally, the examiner found no diagnosable disability for the Veteran’s right shoulder. Therefore, an additional opinion is necessary to ascertain whether any right shoulder disorder is related to a chronic multisymptom illness related to the Veteran’s service in Southwest Asia. 2. Entitlement to service connection for hypertension, to include as secondary to PTSD and/or due to a chronic multisymptom illness is remanded. The Veteran was provided a VA examination in August 2014, and the examiner provided a negative nexus opinion. The examiner found no diagnosis for hypertension; however, the examiner noted the Veteran was prescribed medication to treat hypertension. The Board finds the August 2014 examination is inadequate, for the examiner failed to provide a rationale for finding the Veteran did not have hypertension, even though the Veteran had been prescribed medication to treat hypertension. Barr, 21 Vet. App. at 311; Ardison, 6 Vet. App. at 407. Since the culmination of the VA examination, the Veteran has submitted a medical abstract in July 2013 showing the correlation between hypertension and PTSD. The examiner must address all positive evidence of record in the rationale for any opinion provided. Additionally, the August 2014 VA examination found no diagnosis for hypertension. Therefore, an additional opinion is necessary to ascertain whether any hypertension is related to a chronic multisymptom illness related to the Veteran’s service in Southwest Asia. 3. Entitlement to service connection for a migraine disability, to include as secondary to PTSD and/or due to a chronic multisymptom illness is remanded. The Veteran was provided a VA examination in March 2013. The examiner provided a negative nexus opinion, finding the Veteran’s headaches were not related to active service, and there was no evidence of record that PTSD permanently aggravates any headache pattern. Since the culmination of the VA examination, in July 2013, the Veteran has submitted a March 2011 article showing the correlation between headaches and PTSD. The examiner must address all positive evidence of record in the rationale for any opinion provided. Additionally, due to the Veteran’s service in Southwest Asia, an additional opinion is necessary to ascertain whether any migraine disability is related to a chronic multisymptom illness. The matters are REMANDED for the following action: 1. Make efforts to obtain all outstanding medical records, in accordance with 38 C.F.R. § 3.159(c). 2. After all records are associated with the claims file, obtain a VA opinion with a qualified medical professional regarding the nature and etiology of the Veteran’s right shoulder disorder. The claims file should be made available to the examiner. A new examination may be provided if deemed necessary. The examiner is asked to address the following: (a.) Provide a current (at any point throughout the appeal) diagnosis for any right shoulder disorder; (b.) If the Veteran does not now have, but previously had, any diagnosed disorder, indicate when that disorder resolved; (c.) For each diagnosed disorder, is it at least as likely as not (a 50 percent or greater probability) that the disorder had its onset during or is otherwise related to any event or injury during active duty; (d.) IF a nexus to service cannot be established for any abnormality, please provide an opinion as to whether the disability pattern is consistent with: (1) an undiagnosed illness, (2) a diagnosable but medically unexplained chronic multisymptom illness of unknown etiology, (3) a diagnosable chronic multisymptom illness with a partially explained etiology, or (4) a disease with a clear and specific etiology and diagnosis; and (e.) IF, after reviewing the claims file, it is determined that the Veteran’s disability pattern is consistent with either (3) a diagnosable chronic multi-symptom illness with a partially explained etiology, or (4) a disease with a clear and specific etiology and diagnosis, then please provide a medical opinion as to whether it is at least as likely as not that the disability pattern or diagnosed disease is related to environmental exposures experienced by the Veteran during active duty to include his service in Southwest Asia. In answering all questions, please articulate the reasoning underpinning the conclusions. That is, (1) identify what facts and information--whether found in the record or outside the record--support the opinion, and (2) explain how that evidence justifies the opinion. Relying only on silent service treatment records to support a negative opinion is also not adequate. 3. After all records are associated with the claims file, obtain a VA opinion with a qualified medical professional regarding the nature and etiology of claimed hypertension. The claims file should be made available to the examiner. A new examination may be provided if deemed necessary. The examiner is asked to address the following: (a.) Provide a current (at any point throughout the appeal) diagnosis for any hypertension; (b.) If the Veteran does not now have, but previously had, any diagnosed disorder, indicate when that disorder resolved. This includes an explanation of prescribed medication for hypertension if a current diagnosis is not found; (c.) For each diagnosed disorder, is it at least as likely as not (a 50 percent or greater probability) that the disorder had its onset during or is otherwise related to any event or injury during active duty; or at least as likely as not was caused or aggravated (increased in severity beyond the natural progression of the disorder) by PTSD; (d.) If a nexus to service cannot be established for any abnormality, please provide an opinion as to whether the disability pattern is consistent with: (1) an undiagnosed illness, (2) a diagnosable but medically unexplained chronic multisymptom illness of unknown etiology, (3) a diagnosable chronic multisymptom illness with a partially explained etiology, or (4) a disease with a clear and specific etiology and diagnosis; and (e.) If, after reviewing the claims file, it is determined that the Veteran’s disability pattern is consistent with either (3) a diagnosable chronic multi-symptom illness with a partially explained etiology, or (4) a disease with a clear and specific etiology and diagnosis, then please provide a medical opinion as to whether it is at least as likely as not that the disability pattern or diagnosed disease is related to environmental exposures experienced by the Veteran during active duty to include his service in Southwest Asia. In answering all questions, please articulate the reasoning underpinning the conclusions. That is, (1) identify what facts and information--whether found in the record or outside the record--support the opinion, and (2) explain how that evidence justifies the opinion. Relying only on silent service treatment records to support a negative opinion is also not adequate. All scientific evidence of an association between hypertension and PTSD must be addressed. 4. After all records are associated with the claims file, obtain a VA opinion with a qualified medical professional regarding the nature and etiology of the claimed migraine disability. The claims file should be made available to the examiner. A new examination may be provided if deemed necessary. The examiner is asked to address the following: (a.) Provide a current (at any point throughout the appeal) diagnosis for any migraine disability; (b.) If the Veteran does not now have, but previously had, any diagnosed disorder, indicate when that disorder resolved; (c.) For each diagnosed disorder, is it at least as likely as not (a 50 percent or greater probability) that the disorder had its onset during or is otherwise related to any event or injury during active duty; or at least as likely as not was caused or aggravated (increased in severity beyond the natural progression of the disorder) by PTSD; (d.) If a nexus to service cannot be established for any abnormality, please provide an opinion as to whether the disability pattern is consistent with: (1) an undiagnosed illness, (2) a diagnosable but medically unexplained chronic multisymptom illness of unknown etiology, (3) a diagnosable chronic multisymptom illness with a partially explained etiology, or (4) a disease with a clear and specific etiology and diagnosis; and (e.) If, after reviewing the claims file, it is determined that the Veteran’s disability pattern is consistent with either (3) a diagnosable chronic multi-symptom illness with a partially explained etiology, or (4) a disease with a clear and specific etiology and diagnosis, then please provide a medical opinion as to whether it is at least as likely as not that the disability pattern or diagnosed disease is related to environmental exposures experienced by the Veteran during active duty to include his service in Southwest Asia. In answering all questions, please articulate the reasoning underpinning the conclusions. That is, (1) identify what facts and information--whether found in the record or outside the record--support the opinion, and (2) explain how that evidence justifies the opinion. Relying only on silent service treatment records to support a negative opinion is also not adequate. All scientific evidence of an association between headaches and PTSD must be addressed. A. C. MACKENZIE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. N. Quarles, Associate 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.