Citation Nr: 21024257 Decision Date: 04/22/21 Archive Date: 04/22/21 DOCKET NO. 17-52 083 DATE: April 22, 2021 REMANDED Entitlement to service connection for hypertension, to include as secondary to service-connected posttraumatic stress disorder (PTSD), is remanded. Entitlement to service connection for a neurological disability is remanded. Entitlement to service connection for a respiratory disability, to include asthma, is remanded. Entitlement to a rating in excess of 10 percent for a left ankle disability is remanded. REASONS FOR REMANDED The Veteran had active naval service from October 1983 to November 1986. This case comes before the Board of Veterans’ Appeals (Board) on appeal of a July 2014 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In January 2021, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A transcript of that hearing is associated with the claims file. At the outset, the Board notes that the issue of service connection has been recharacterized as service connection for a respiratory disorder, to include asthma, in accordance with Clemons v. Shinseki, 23 Vet. App. 1 (2009). Hypertension The Veteran’s service treatment records (STRs) reveal that he had one instance of elevated blood pressure in December 1985. In November 2015, the Veteran was afforded a VA examination for hypertension. At that time, the Veteran reported that he went on medication for hypertension in 2000, and that he took Lisinopril with good control. The VA examiner noted that the Veteran had a diagnosis of hypertension. However, the VA examiner opined that the Veteran’s hypertension was less likely as not incurred in or caused by the diving incident during his in-service training. The VA examiner reasoned that there was not sufficient evidence of continuing and recurrent or persistent hypertension. The VA examiner also noted that delayed effects of diving accidents generally occur shortly after the injury. In a December 2016 statement, the Veteran’s wife stated that the Veteran initially had elevated blood pressure that finally required medication to control. She also stated that when the Veteran became agitated or anxious his blood pressure would spike and stay high regardless of the fact that he took medication daily. In August 2017, the Veteran was afforded another VA examination for hypertension. At that time, the Veteran reported that he started blood pressure medication in the Fall of 2000 and that he started Lisinopril two to three years later. The VA examiner opined that the Veteran’s hypertension was less likely than not incurred in or caused by his active service. The VA examiner reasoned that hypertension was not reported to be a long-term risk of decompression sickness. The VA examiner also noted that stroke and myocardial infarction were noted to be risks but that the Veteran did not have either condition nor did either condition cause essential hypertension. During the January 2021 Board hearing, the Veteran stated that he believed his hypertension was secondary to his PTSD. At that time, the Veteran stated that he met other veteran’s with PTSD who had similar symptoms. The Veteran also stated that he had a stressful job and that his blood pressure would raise quickly at times. The Board notes that the November 2015 and August 2017 VA examiners were only requested to provide an opinion as to whether the Veteran’s hypertension was due to his active service. Therefore, although the Board finds that the November 2015 and August 2017 VA examiner’s provided a clear basis for their opinions that the Veteran’s hypertension did not manifest in service, the Board finds that an addendum opinion is necessary to address whether the Veteran’s hypertension was proximately due to, or aggravated by, his service-connected PTSD. Neurological Disability In a December 2016 statement, the Veteran’s wife stated that the Veteran had hand tremors when she first met him, shortly after his in-service decompression sickness. She also stated that the Veteran’s tremors were slight and infrequent, but became moderate and constant and that he could not carry a cup of coffee without spilling it. In August 2017, the Veteran was afforded a VA examination for central nervous system (CNS) and neuromuscular diseases. At that time, the Veteran reported that his tremors started approximately September 1984 and got worse when he was excited or stressed. The Veteran also noted that his shakiness varied in severity but was getting worse. The VA examiner noted that the Veteran had a diagnosis of essential tremor and a fine action tremor of both hands, but no resting tremor. The VA examiner ultimately assessed that the Veteran’s essential tremor was less likely than not incurred in or caused by his active service. The VA examiner reasoned that the Veteran’s essential tremors of the bilateral upper extremities were a common condition that effected five percent of adults worldwide and not a long-term consequence of decompression sickness or diving. Additionally, the VA examiner reported that there was nothing on examination to suggest that the Veteran’s tremors were the result of a specific neurological insult. During the January 2021 Board hearing, the Veteran testified that he shook uncontrollably when attempting to do tasks. The Veteran also stated that he believed his shakes were a side effect of trauma and secondary to his PTSD or decompression sickness. The Board finds that the August 2017 VA opinion is inadequate for adjudication purposes. In that regard, the VA examiner failed to address the lay statements of the Veteran and his wife. Additionally, the VA examiner’s rationale was contradictory as she noted that CNS was common but then reported that only five percent of adults world-wide had the condition, which indicates that it is not common. Further, the VA examiner failed to address the etiology of the Veteran’s tremors entirely. Based on the foregoing, a remand is warranted for an addendum opinion to determine the etiology of the Veteran’s neurological disability, to include as secondary to his service-connected PTSD. Respiratory Disability The Veteran service treatment records (STRs) reveal that in April and December 1984, and in August 1986, the Veteran was collectively seen for complaints of congestion, sore throat, productive cough, head congestion, and muscle aches. At those times, the Veteran was diagnosed with an upper respiratory infection (URI). Additionally, in November 1985, the Veteran was noted as having a viral syndrome. In March 2014, a private medical note documented that the Veteran was prescribed fluticasone. In June 2014, a private medical note documented that the Veteran was prescribed several medications for asthma prevention and control. In an October 2015 private urgent care note, the Veteran was seen for complaints of shortness of breath and assessed as having asthma. In November 2015, the Veteran was afforded a VA examination for respiratory conditions. At that time, the Veteran reported that he was diagnosed with asthma in 2006. The Veteran also stated that on hot and sunny days, in dusty environments, his asthma was aggravated. The VA examiner noted that the Veteran had a diagnosis of asthma. However, the VA examiner opined that the Veteran’s asthma was less likely than not incurred in or caused by his active service. The VA examiner reasoned the Veteran’s asthma advanced in conjunction with his environmental allergies and varied in intensity with the severity of his allergy symptoms. The VA examiner also noted that potential long-term consequences of diving and/or decompression sickness were reported airflow obstruction that would cause permanent damage, unlike symptoms due to inflammation that were reversible, such as asthma; and, that delayed effects of diving accidents generally occurred after injury. Additionally, the VA examiner noted that the strong associations between atopy (sensitivity to specific allergens), allergic disease and asthma were well documented. Further, the VA examiner stated that the Veteran did not report respiratory and asthma symptoms persisting from service to the present. In a December 2016 statement, the Veteran’s wife stated that the Veteran began with moderate allergies which became severe asthma that required daily medication. The Veteran’s wife noted that no one in the Veteran’s family suffered from asthma. In August 2017 the Veteran was afforded another VA examination for respiratory conditions. At that time, the Veteran reported that he was diagnosed with asthma around late 2006. The Veteran also reported that he had been treated with albuterol for shortness of breath and other symptoms that accompanied exacerbations of his hay fever since about 1997 or 1998. The VA examiner noted that the Veteran had a current diagnosis of asthma. However, the VA examiner assessed that the Veteran’s asthma was less likely than not incurred in or caused by his active service. The VA examiner used the exact same reasoning as the November 2015 VA examiner to support that conclusion. During the January 2021 Board hearing, the Veteran stated that a doctor informed him that his asthma could be related to decompression sickness or the physiological side effects of diving. The Board finds that the November 2015 and August 2017 VA medical opinions are inadequate for adjudication purposes. In that regard, the VA examiners collectively failed to consider the Veteran and his wife’s lay statements. Additionally, the August 2017 VA examiner failed to incorporate relevant evidence pertaining to the Veteran’s documented URIs during his active service and his post-service prescription of fluticasone and diagnosis of seasonal allergies. Based on the foregoing, the Board finds that a remand is warranted to obtain an addendum opinion in regard to the nature and etiology of any currently present respiratory disability. Increased Rating – Left Ankle Disability The Veteran was last afforded a VA examination for his service-connected left ankle disability in November 2015. During the January 2021 Board hearing, the Veteran testified that his ankle pain, discomfort, and instability had worsened since his last VA examination. Therefore, the Board finds that the Veteran should be afforded a new VA examination to determine the severity of any currently present left ankle disability. The matter is REMANDED for the following action: 1. Identify and obtain any pertinent, outstanding VA and private treatment records and associate them with the claims file, to include, if possible, any medical records pertaining to the Veteran’s initial asthma diagnosis in 2006. 2. Then, schedule the Veteran for an examination to determine the nature and etiology of his hypertension. The claims file must be made available to, and reviewed by the examiner. Any indicated tests and studies must be performed. Based on the examination results and review of the record, the examiner must provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s hypertension is caused or aggravated by a service-connected disability, to include his PTSD. In forming the opinion, the examiner must consider the Veteran’s lay statements regarding increased severity of his hypertension during times of significant stress. A complete and detailed rationale for all opinions expressed must be provided. 3. Then, schedule the Veteran for an examination to determine the nature and etiology of any currently present neurological disability, to include tremors. The claims file must be made available to, and reviewed by the examiner. Any indicated tests and studies must be performed. Based on the examination results and review of the record, the examiner must provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any currently present neurological disability had its onset during the Veteran’s active service, or is otherwise etiologically related to such service, to specifically include the Veteran’s history of diving and decompression sickness. In forming the opinion, the examiner must consider the lay statements of record regarding the onset and continuity of the Veteran’s symptoms. The examiner must also provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any currently present neurological disability was caused or aggravated by a service-connected disability, to specifically include stress caused by PTSD. In forming the opinion, the examiner must consider the Veteran’s lay statements regarding increased severity of his tremors during times of significant stress. A complete and detailed rationale for all opinions expressed must be provided. 4. Then, schedule the Veteran for an examination to determine the nature and etiology of any currently present respiratory disability, to include asthma. The claims file must be made available to, and reviewed by the examiner. Any indicated tests and studies must be performed. Based on the examination results and review of the record, the examiner must provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any currently present respiratory disability had its onset during the Veteran’s active service, or is otherwise etiologically related to such service, to specifically include the Veteran’s history of in-service upper respiratory infections and allergies. In forming the opinion, the examiner must consider the lay statements of record regarding the onset and continuity of the Veteran’s symptoms. A complete and detailed rationale for all opinions expressed must be provided. 5. Then, schedule the Veteran for a VA examination to assess the severity of his service-connected left ankle disability. The claims file must be made available to and reviewed by the examiner. Any indicated tests and studies must be performed. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. 6. Confirm that the VA examination report and medical opinions comport with this remand and undertake any other development determined to be warranted. 7. Then, readjudicate the appeal. If a decision is adverse to the Veteran, issue a supplemental statement of the case and allow appropriate time for a response. Then, return the case to the Board. Kristin Haddock Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Byrd, 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.