Citation Nr: 21062475 Decision Date: 10/07/21 Archive Date: 10/07/21 DOCKET NO. 18-18 452 DATE: October 7, 2021 REMANDED Entitlement to a compensable rating for a chronic bronchitis disability is remanded. Entitlement to service connection for a heart condition. is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Navy from October 1968 to July 1970. 1. Entitlement to a compensable rating for a chronic bronchitis disability is remanded. The Board finds that the May 2016 VA examination provided to the Veteran was inadequate. Namely, the Board is confused by a portion of the May 2016 VA examination wherein the examiner checked the box that the Veteran had additionally symptoms associated with the claimed condition and wrote "chest cta, no rhonchi, rales or wheezing, rr-14, 02 sat 99%." It appears the examiner is excluding symptoms while writing no rhonci, rales or wheezing and documenting oxygen saturation of 99 percent. However, the remark "chest CTA" appears to refer to imaging, but not imaging outside of a 2013 x-ray is mentioned in the examination report." Considering the foregoing, the Board finds that the May 2016 VA examination is, in part, inadequate. The United States Court of Appeal for Veterans Claims has held that that once VA undertakes the effort to provide an examination when developing a claim, even if not statutorily obligated to do so, VA must ensure that the examination provided is adequate. See Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007). Therefore, the Board finds a new VA examination is warranted. 2. Entitlement to service connection for a heart condition. is remanded. The Board finds that the May 2016 VA examination provided to the Veteran was inadequate. Curiously, while the examiner documents the Veteran's report of stroke in 2015, he turns to the Veteran's 2013 chest x-ray in determining that the Veteran has no current heart disability. The Board emphasizes that VA must ensure that the examination provided is adequate; here, the reliance on imaging which preceded the Veteran's claimed stroke makes the VA examination inadequate. See Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007). Therefore, the Board finds a new VA examination is warranted. The matters are REMANDED for the following action: 1. Contact the Veteran and request that he identify the names, addresses, and approximate dates of treatment for all VA and non-VA health care providers who have treated him for his disabilities. The Veteran should be requested to sign any necessary authorization for release of medical records to VA, and appropriate steps should be made to obtain any identified records. Regardless of the Veteran's response, VA treatment records should be collected from the VA Northern California Health Care System and all associated outpatient center and clinics. In particular, the AOJ should retrieve VA treatment records from February 2018 to present should be collected. Any archived records should be retrieved from storage. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file. If the records are unavailable, notify the Veteran in accordance with 38 C.F.R. § 3.159. 2. After the above development is accomplished, schedule the Veteran for appropriate VA examinations. The claims folder (including a copy of this remand) must be provided to and reviewed by the examiners as part of the examination. A notation to the effect that this review has taken place should be made in the evaluation report. (A) BRONCHITIS: The VA examiner should determine the nature and severity of the Veteran's bronchitis disability. All tests, studies, and evaluations should be performed as deemed necessary by the examiners, and the results of any testing must be included in the examination report. Any opinion provided should be accompanied by a supporting rationale. (B) HEART CONDITION: After considering the pertinent information in the record in its entirety, the VA examiner should identify any heart disabilities present. The examiner is asked to opine as to whether it is at least as likely as not i.e. 50 percent probability or greater, that any heart disability identified was incurred or aggravated by his active duty OR whether it is at least as likely as not caused by or aggravated by his bronchitis disability. In providing an opinion, the examiner should: (i) take a detailed history from the Veteran regarding the onset of this disability and any continuity of symptoms since that time; (ii) comment on a May 2015 private treatment note wherein the Veteran's private physician wrote, "Echocardiogram done at Kaiser indicates that cardiac compromise is due to lung disease." All tests, studies, and evaluations should be performed as deemed necessary by the examiners, and the results of any testing must be included in the examination report. 3. Ensure that the examination report complies with this remand and the questions presented in this request. If the report is insufficient, it must be returned to the examiner for necessary corrective action, as appropriate. 4. After completing the requested actions and any additional notification and/or development deemed warranted, readjudicate the issues on appeal. GAYLE STROMMEN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Acosta, 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.