Citation Nr: 21067248
Decision Date: 11/03/21	Archive Date: 11/03/21

DOCKET NO. 09-40 308
DATE: November 3, 2021

REMANDED

Entitlement to service connection for a cardiovascular disorder, to include hypertension, dilated cardiomyopathy, and congestive heart failure, on a direct basis or as secondary to service-connected left kidney hydronephrosis, is remanded.

REASONS FOR REMAND

Having reviewed the record, the Board finds remand is warranted.  The June 2021 VA examiner stated that further investigation is needed to locate a 1988 service treatment record (STR) noting symptoms of hydronephrosis such as pain in his left lower side, nausea, and vomiting.  However, the Board notes that this STR already appears to be of record.  Specifically, a June 1988 STR documented complaints of pain in the left side with nausea and an August 1988 STR documented emergency care and treatment for stomach cramps and vomiting with mild tenderness to the left back area.  As the examiner does not appear to have had access to and/or reviewed these records, remand is warranted for an addendum opinion on whether a claimed cardiovascular condition is at least likely as not related to service.  The examiner should also consider the following relevant STRs: a January 1990 complaint of nausea and vomiting and an October 1990 complaint of vomiting and pain in lower left side of back.

Additionally, the June 2021 examiner noted that further investigation is needed to locate a potential 1991 private treatment record regarding dye imaging of the kidney.  Accordingly, an effort should be made to obtain any such record with the proper authorization from the Veteran.  

As an additional matter, the Board notes that the record contains a December 1992 intravenous pyelogram report of the kidneys.  As the examiner does not appear to have had access to and/or reviewed this record, remand is warranted for an addendum opinion that considers the December 1992 intravenous pyelogram report as well. 

Finally, any outstanding VA treatment records should be obtained and associated with the claims file. 

The matter is REMANDED for the following actions:

1. Ask the Veteran to complete a VA Form 21-4142 for a 1991 private treatment record regarding dye imaging of the kidney.  Make two requests for the authorized records unless it is clear after the first request that a second request would be futile.

2. Obtain the Veteran's VA treatment records for the period from June 2021 to present. 

3. After completion of Directive 1, obtain an addendum opinion from an appropriate clinician regarding the following:

(a) Whether the Veteran's claimed cardiovascular condition (to include hypertension, dilated cardiomyopathy, and congestive heart failure) is at least as likely as not related to service, to include in-service complaints and treatment for nausea, vomiting, and/or pain in the left back as noted in June 1988, August 1988, January 1990, and October 1990 STRs.

Attention is also invited to a post-service December 1992 intravenous pyelogram report of the kidneys, noting an impression of nonfunctioning or absent left kidney.

(b) Whether the Veteran's claimed cardiovascular condition (to include hypertension, dilated cardiomyopathy, and congestive heart failure) at least as likely as not is (i) proximately due to or (ii) aggravated by service-connected left kidney hydronephrosis.  The examiner should consider in-service complaints of nausea, vomiting, and/or pain in the left back as noted in June 1988, August 1988, January 1990, and October 1990 STRs.

Attention is also invited to a post-service December 1992 intravenous pyelogram report of the kidneys, noting an impression of nonfunctioning or absent left kidney.

 

 

TANYA SMITH

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	S. Vang, 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.