Citation Nr: 20054561 Decision Date: 08/18/20 Archive Date: 08/18/20 DOCKET NO. 14-35 061A DATE: August 18, 2020 REMANDED Entitlement to service connection for hypertension is remanded. REASONS FOR REMAND Entitlement to service connection for hypertension is remanded. The VA treatment records currently in evidence contain notations indicating that a VA employee scanned medical records into a VA hospital's imaging system, but do not contain any copies of the scanned records. Any treatment records scanned into a VA hospital's imaging system are within VA's constructive possession and are considered potentially relevant to the issues on appeal. Remand is required to allow VA to obtain those records. In April 2018, the Board reopened the claim for service connection for hypertension. In reopening the claim, the Board noted that an August 1988 service medical record contained a diastolic blood pressure reading suggestive of high blood pressure. The Board remanded the reopened claim for the scheduling of a VA examination to determine the etiology of the claimed disability. In a February 2020 VA medical opinion, written in attempted compliance with the Board's remand instructions, a VA examiner, following an examination, opined that the Veteran's hypertension was not at least as likely as not related to the Veteran's service, because the March 1991 service separation examination contained a normal blood pressure reading, and the service medical records did not include any notation indicating diagnosis or treatment for hypertension. However, the examiner did not note the August 1988 service medical record in which a service examiner noted that the Veteran had a diastolic blood pressure reading suggestive of high blood pressure. Remand is necessary to schedule an additional examination. The matters are REMANDED for the following action: 1. Obtain all outstanding VA treatment records. Specifically, obtain the most recent VA treatment records not included in the record of evidence and the records noted as having been scanned into the Vista imaging system by VA Medical Center personnel, as noted in the VA treatment records in evidence, dated June 19, 2018; August 27, 2015; April 27, 2015; May 22, 2014; June 22, 2013; November 8, 2012; June 21, 2012; June 21, 2012; January 11, 2012; and January 19, 2011. 2. Schedule the Veteran for a VA medical examination with a VA internist to determine the nature and etiology of the claimed hypertension disability. The examiner must review the claims file prior to writing the required opinions. In reviewing the claim file, the examiner must note the service medical records, to include the August 1988 service medical record in which a service examiner noted a diastolic reading suggestive of high blood pressure; the post-service treatment records; and the lay evidence, to include the Veteran's statements indicating in-service onset of hypertension. The examiner must offer the following opinions: (a.) Is the Veteran's hypertension at least as likely as not (50 percent or greater probability) related to service, or any event injury or disease during service? Discuss the significance of an August 1988 service medical record showing elevated blood pressure. (b.) Is it at least as likely as not (50 percent or greater probability) that the Veteran's hypertension disability (1) began during active service, (2) manifested within one year after the Veteran's October 1991 separation from service, or (3) was noted during service with continuity of the same symptomatology since service? Harvey P. Roberts Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Department of Veterans Affairs 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.