Citation Nr: 21008137 Decision Date: 02/11/21 Archive Date: 02/11/21 DOCKET NO. 13-29 320 DATE: February 11, 2021 REMANDED Entitlement to service connection for hypertension, to include as secondary to service-connected posttraumatic stress disorder (PTSD), is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1969 to April 1974. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a December 2011 rating decision by the Department of Veterans Affairs (VA) New Orleans, LA Regional Office (RO). This matter was remanded by the Board in December 2019 for additional development. Such development has been completed and the matter returned to the Board for appellate consideration. The Veteran was provided with a hearing before the undersigned Veteran’s Law Judge in October 2014. 1. Entitlement to service connection for hypertension, to include as secondary to service-connected PTSD, is remanded. Though the Board regrets additional delay, remand is required for an adequate VA examination opinion. Where VA provides the Veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The Veteran was provided with a VA examination in January 2020. The examiner found that it was less likely than not that the Veteran’s hypertension was related to his service or caused or aggravated by his PTSD. He stated that the Veteran’s PTSD was not severe enough to cause or aggravate the Veteran’s hypertension. The examiner noted that the Veteran was not seen regularly enough by mental health professionals to indicate a significant PTSD condition. The examiner also found that the Veteran was not on any psychotropic medications which also indicated a mild PTSD condition. The examiner noted that a review of the Veteran’s mental health records showed that his providers did not designate the Veteran’s PTSD as significant. The examiner determined that the Veteran’s hypertension was more likely due to his other risk factors such as genetic reduction in renal nephron numbers, his history of tobacco use, his history of opioid abuse, his history of alcohol abuse, and his sedentary lifestyle. The examiner stated that there was no evidence that the Veteran was diagnosed with hypertension in service or within one year of discharge. The examiner acknowledged that there were two instances in service where the Veteran had elevated blood pressure levels. It was noted that both readings were taken during acute mental health episodes, with one being taken during an anxiety attack and the other reading being taken during a suicide attempt. The examiner noted that the Veteran’s blood pressure elevation was only mild during these episodes and that they were a normal psychological response to stress and not a permanent hypertension condition. The examiner then addressed the Veteran’s possible in-service stressors and stated that the Veteran was not engaged in combat on a daily basis. The examiner stated that he had personally been stationed in the same area of Vietnam as the Veteran one year prior and that the area had been pacified at the time, with little enemy activity. The examiner then listed several non-military stressors in the Veteran’s life, but stated that he would respect the Veteran’s service connection for PTSD. The examiner stated that there was a scarcity of mental health treatment in the Veteran’s records to which he had access, starting in 2015. The examiner then reemphasized that the Veteran’s PTSD could not have been severe as he was not on any medications. The examiner stated that the mild nature of the Veteran’s PTSD and the fact that the Veteran was not on medication for PTSD but was on medication for hypertension through certain periods in his life indicated that the Veteran’s hypertension was less likely than not caused or aggravated by PTSD. The Board finds this opinion to be inadequate as the examiner failed to address all the medical evidence of record. The examiner largely supported his opinion on the fact that the Veteran did not receive consistent mental health treatment for his PTSD nor was he prescribed any psychotropic medications. The examiner then noted that he had only reviewed medical records beginning in 2015. The Veteran’s claims file includes VA medical records from 2008 many of which are psychology notes. Several of the medical records also noted psychotropic medication regimens that the Veteran underwent to treat his mental health symptoms. October 2009, May 2010, and July 2012 VA records listed the Veteran’s prescribed medications such as Zolpidem, Venlafaxine, Sertraline, etc. February 2014 VA records noted that the Veteran’s drug trials with many of these medications failed as the Veteran could not tolerate the symptoms of headaches and fogginess. February 2015 VA records noted that the Veteran had been switched to Citalopram. More recent VA medical records noted that the Veteran was not taking psychotropics, but instead attempting to cope with his mental health symptoms through therapy. As the examiner failed to address these medical records, remand is required for an adequate VA examination. The Board also finds that it is unable to rely upon this opinion to be inadequate as it appears to call into question the basis for the grant of service connection for PTSD - the examiner utilized his own personal experience as objective truth in opining that the Veteran did not experience heightened stress in service. In finding that the Veteran’s hypertension was less likely than not caused by his military service, the examiner stated that the Veteran had not seen direct combat daily and that the Veteran’s service in Vietnam was likely peaceful as he had been deployed to the same area the year prior and the region had been deemed pacified. The examiner’s comment is his own personal opinion, which is not entirely probative. See Wise v. Shinseki¸26 Vet. App. 517 (2014). Finally, the Board notes that on remand, the examiner should address whether the Veteran was prehypertensive prior to service. In the October 2014 hearing, the Veteran’s representative noted that the Veteran’s blood pressure reading on the entrance examination was elevated and that the Veteran was likely prehypertensive when he entered service. The representative stated that this prehypertensive condition made the Veteran more vulnerable to the stresses of his mental health conditions, which then affected his blood pressure. The examiner was asked to determine whether the Veteran may have been prehypertensive in the June 2015 Board remand directives. The Board notes that the examiners from the May 2016 and January 2020 VA examinations did not properly address this. As such, remand is required to address these inadequacies. The matters are REMANDED for the following action: 1. Contact the appropriate VA Medical Centers and obtain and associate with the claims file all outstanding records of treatment. 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. Efforts to obtain these records must continue until it is determined that they do not exist or that further attempts to obtain them would be futile. The non-existence or unavailability of such records must be verified, and this should be documented for the record. Required notice must be provided to the Veteran and his or her representative. 2. After any additional records are associated with the claims file, provide the Veteran with an appropriate examination to determine the etiology of the Veteran’s hypertension. If possible, the examination shall be conducted by an examiner other than the 2020 VA examiner. The entire claims file must be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished, and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. The relevant Disability Benefits Questionnaire must be utilized. The examiner must provide the following opinions: Is it at least as likely as not (50 percent or greater possibility) that the Veteran had its onset in or was caused by military service? Is it at least as likely as not (50 percent or greater possibility) that the Veteran’s hypertension was caused or aggravated by PTSD? The examiner must also comment on the Veteran’s assertion that he was prehypertensive prior to service. The examiner must specifically address the Veteran’s credible lay statements, all the medical evidence of record, and any medical principles used in providing the above-noted opinion. K. MILLIKAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board AK 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.