Citation Nr: 21065743 Decision Date: 10/27/21 Archive Date: 10/27/21 DOCKET NO. 08-19 030 DATE: October 27, 2021 REMANDED Entitlement to a total disability rating for compensation based on individual unemployability due to service-connected disabilities (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1973 to January 1976. This matter returns to the Board of Veterans' Appeals (Board) following a Joint Motion for Remand (Joint Motion) granted by the United States Court of Appeals for Veterans Claims (Court) which vacated and remanded a September 2020 Board decision denying the Veteran's TDIU claim. In the Joint Motion, the parties agreed that vacatur and remand of the issue of TDIU is warranted in order to obtain a new medical opinion relating to the Veteran's service-connected hypertension that provides an adequate rationale. The September 2020 Board decision relied, in part, on an October 2015 VA examination opinion, which stated that "there is currently insufficient evidence to suggest the Veteran's hypertension prevents the Veteran from securing or follow[ing] a substantial gainful occupation due to the service-connected disabilities of hypertension." The examiner noted that the Veteran's blood pressure was under control with the use of medication. However, the parties found that the examiner failed to reconcile the above opinion with the Veteran's report that his blood pressure "becomes very elevated during times of stress and increased work related pressure, causing him to become dizzy and have severe headaches." The Veteran noted that "this is one of the reasons he has stopped working since 2007." Accordingly, remand is warranted in order to obtain an adequate VA examination opinion. The matter is REMANDED for the following action: Schedule the Veteran for a VA examination with an appropriate clinician to provide an opinion as to the current severity of the Veteran's hypertension. The examiner should review the file and be provided with a copy of the facts listed below. To assist the examiner in a review of the claims file, the examiner is informed of the following facts with citations in the record, when applicable: The Veteran served on active duty from June 1973 to January 1976. The Veteran is service connected for hypertension. The Veteran has a college education. Of record are VA treatment records dated from March 2002 to March 2021. Diastolic blood pressure readings from March 2002 to December 2019 documented within the VA treatment records range from 60 to 106 with approximately seven (7) readings between 100 and 106. Systolic blood pressure readings during this time period ranged from 102 to 170 with approximately six (6) readings of 160 and above. During this period of time, there are notations of VA attempting to control the Veteran's blood pressure when he had elevated blood pressure readings. VA treatment records show the Veteran reported "occasional headaches" in July 2006 and September 2006, but then consistently denied experiencing headaches from November 2006 to June 2020. A May 2013 VA treatment record shows the Veteran was seen and documented to have an elevated blood pressure reading of 160/102. The Veteran reported he had been under stress living with his brother for the last week. He reported experiencing dizzy spells the last four days with the last spell of dizziness occurring in 2004, when he was in Los Angeles. See VBMS entry with document type, "CAPRI," receipt date 04/13/2016, p. 180. In an Addendum to the above May 2013 treatment record, the examiner wrote that the Veteran had been seen briefly, had arguments with brother this past week, and that he had experienced "some dizziness off and on when upset." The examiner noted the Veteran's blood pressure was elevated in oncology to 160/102 but on repeat with nurse, it was 136/90. The examiner also documented there was no dizziness, no ataxia, and no aphasia. Lisinopril was added the Veteran's hypertension medication. See VBMS entry with document type, "CAPRI," receipt date 04/13/2016, p. 180. In March 2014, the Veteran underwent a VA examination for assessment of the service-connected hypertension in March 2014. The blood pressure readings taken at that time were 130/90, 130/100, and 130/90. The examiner stated that the Veteran's hypertension does not impact his ability to work. See VBMS entry with document type, "C&P Exam," receipt date 03/19/2014, pp. 2-4. The Veteran underwent another VA examination in October 2015. He reported to the examiner that his hypertension, though usually controlled, becomes very elevated during times of stress and increased work-related pressure, causing him to become dizzy and have severe headaches. He claimed this to be one of the reasons he stopped working in 2007. The blood pressure readings taken at that time were 130/90, 131/92, and 133/92. Following a physical examination, the examiner concluded that the Veteran is not functionally impaired as it relates to his hypertension and can entertain both physical and sedentary employment. Specifically, the examiner wrote "there is currently insufficient evidence to suggest the Veteran's hypertension prevents the Veteran from securing or follow[ing] a substantial gainful occupation due to the service-connected disabilities of hypertension." The examiner added that the Veteran was on blood pressure medication and his current blood pressure was under control. See VBMS entry with document type, "VA Examination," receipt date 10/13/2015, pp. 1-6. The examiner, in providing the above conclusion, however, did not address the Veteran's report to the October 2015 examiner regarding the following symptoms: "The Veteran claims that his hypertension, though usually controlled, becomes very elevated during times of stress and increased work[-]related pressure, causing him to become dizzy and have severe headaches. He claims that this is one of the reasons he has stopped working since 2007. He is currently on 2 medications for his high blood pressure." See VBMS entry with document type, "VA Examination," receipt date 10/13/2015, p. 2. VA treatment records from May 2015 to October 2020 show the Veteran consistently denied headaches, chest pain, and dizziness. The examiner's review of the record is NOT restricted to the evidence listed above. This list is provided to assist the examiner in locating potentially relevant evidence. Following a review of the evidence, the examiner is asked whether it is at least as likely as not (50 percent or greater probability) that the Veteran was unable to secure or follow a substantially gainful occupation due to the service-connected hypertension. In answering this question, the examiner is asked to discuss the Veteran's contentions that his hypertension becomes very elevated during times of increased stress, causing him dizziness and severe headaches. A full rationale, including reference to supporting clinical data and/or medical literature as deemed appropriate, must be provided for all medical opinions given. A. P. SIMPSON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board G. Wonderling, 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.