Citation Nr: 21068332 Decision Date: 11/10/21 Archive Date: 11/10/21 DOCKET NO. 16-58 237 DATE: November 10, 2021 REMANDED The claim of entitlement to service connection for hypertension is remanded. The claim of entitlement to service connection for arteriovenous fistula is remanded. The claim of entitlement to service connection for cerebral aneurysm is remanded. The claim of entitlement to service connection for migraine headaches is remanded. The claim of entitlement to service connection for an acquired psychiatric disorder, to include adjustment disorder (claimed as somatization disorder), is remanded. REASONS FOR REMAND The Veteran had honorable active duty service in the United States Army from July 1973 to July 1975. These matters come before the Board of Veterans' Appeals (Board) from an April 2016 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In June 2018 the Board remanded these matters to the RO for additional development, to include obtaining outstanding treatment records and to provide medical examinations regarding the claimed conditions. On remand, the RO requested information from the Veteran regarding treatment received from private providers. See March 2019 development letter. The record reflects that the RO received no response from the Veteran. Further, the record shows that the RO obtained outstanding VA treatment records since January 1999 and completed medical examinations regarding the Veteran's claimed conditions. Regrettably, it appears that there are outstanding service treatment records relating to the claimed in-service incident. Specifically, the Veteran's active service Record of Assignments shows that he was in "patient" status from August 3, 1973 to approximately August 16, 1973, which was just days following the start of his active service. According to the Veteran and a lay statement from his mother, who has the initials E.T.S., the claimed in-service grenade injury occurred in August 1973. This letter and other evidence show that the Veteran had possibly related treatment at a VA hospital shortly after his discharge. See August 2016 lay statement; April 1977 VA Form 10-7131. Additionally, there is evidence that the Veteran had service in the Army Reserve or National Guard immediately following his active duty. See April 2000 VA Form 21-526 Pension Application. As the records described above are not currently of record and may provide evidence regarding the existence or severity of the Veteran's claimed in-service incident, efforts should be made to obtain them. Remand is therefore warranted to obtain these outstanding records, to obtain medical opinions based on the Veteran's complete medical history and service medical records, and to ensure substantial compliance with the Board's previous remand instructions. See 38 U.S.C. § 5103A, Stegall v. West, 11 Vet. App. 268, 270-71 (1998); 38 C.F.R. § 3.159. This appeal has been advanced on the Board's docket pursuant to 38 U.S.C. § 7107(a)(2) and 38 C.F.R. § 20.902(c). 1. The claim of entitlement to service connection for hypertension is remanded. See section 5 below. 2. The claim of entitlement to service connection for arteriovenous fistula is remanded. See section 5 below. 3. The claim of entitlement to service connection for cerebral aneurysm is remanded. The Veteran contends that his cerebral aneurysm is a result of his military service. Specifically, the Veteran asserts that his cerebral aneurysm is related to an injury from a grenade blast during his military basic training. Medical treatment records indicate the Veteran has a current diagnosis of cerebral aneurysm for which he received treatment and had surgery and that he has residual symptoms from the aneurysm. As noted earlier in this decision, VA hospital records and service medical relating to the in-service grenade blast and any resulting injuries are not of record. See Record of Assignments showing treatment at MHC USA MEDDAC, Ft. Jackson, South Carolina beginning August 3, 1973. It appears that post-service VA hospital records and Reserve or National Guard service medical records are also outstanding. Current medical examinations and opinions should be obtained once these records are gathered. Remand is therefore warranted. 4. The claim of entitlement to service connection for migraine headaches is remanded. See section 5 below. 5. The claim of entitlement to service connection for an acquired psychiatric disorder, to include adjustment disorder (claimed as somatization disorder), is remanded. The Veteran contends that his hypertension, arteriovenous fistula, migraine headaches, and acquired psychiatric condition are a result of his military service, to include as secondary to his cerebral aneurysm. Medical treatment records indicate the Veteran has a post-service history of and current diagnoses for these conditions. As outlined above, records remain outstanding that may be relevant to the Veteran's claims. Remand is warranted to obtain these records and to obtain medical examination or addendum reports, as necessary. The matters are REMANDED for the following action: 1. These matters are advanced on the Board's docket. 2. Obtain the Veteran's service medical records, to include any hospital records from August 1973 relating to the claimed grenade blast incident at Fort Jackson, South Carolina. Please refer to Veteran's in-service Record of Assignments showing "patient" status from August 3, 1973 to August 16, 1973 at MHC USA MEDDAC, Ft. Jackson, South Carolina. All efforts to obtain these records should be documented in the claims file. 3. Obtain VA Hospital records from 1975 to 1980 from the New York VA Hospital. Refer to August 2016 lay statement; April 26, 1977 VA 10-7131 for details. All efforts to obtain these records should be documented in the claims file. 4. Obtain any and all service medical records from the Veteran's reserve service in the Army National Guard in Puerto Rico from July 1975 to July 1976.. See April 2000 VA 21-526 Pension Application. All efforts to obtain these records should be documented in the claims file. 5. After the above development is complete, return the Veteran's claims file to the clinicians who previously examined the Veteran in April 2021 and September 2021 (or to another appropriate clinician, if these clinicians are unavailable). These clinicians must consider all newly obtained information of the Veteran's claimed conditions and provide updated opinions regarding the nature and etiology of the Veteran's acquired psychiatric disorder, hypertension, arteriovenous fistula, cerebral aneurysm, and migraine headaches. New examinations should be scheduled if necessary. All indicated tests should be completed. The clinicians shall address whether it is at least as likely as not (50 percent or greater probability) that any of the claimed conditions: (1) began during active service; (2) manifested within one year of active duty service; or (3) is otherwise related to service to include the Veteran's claimed injury due to a grenade blast during military basic training. The clinicians should provide complete rationale for all opinions expressed and conclusions reached. 6. Following completion of the above, the Agency of Original Jurisdiction (AOJ) should review the record and ensure adequacy of the post-remand development. If the claims remain denied, the AOJ should issue an appropriate supplemental Statement of the Case, afford the Veteran and his representative an opportunity to respond, and return the case to the Board. B. MULLINS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Hart, 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.