Citation Nr: 21027717 Decision Date: 05/06/21 Archive Date: 05/06/21 DOCKET NO. 16-33 911 DATE: May 6, 2021 Entitlement to an initial rating of 70 percent, but no higher, for service-connected adjustment disorder with depressed mood is granted. From July 28, 2011, entitlement to a total disability rating based on individual unemployability (TDIU) is granted. REMANDED Entitlement to service connection for hypertension, to include as secondary to service-connected adjustment disorder with depressed mood, is remanded. Entitlement to service connection for a bilateral knee disability is remanded. Entitlement to service connection for acid reflux, to include as secondary to adjustment disorder with depressed mood, is remanded. FINDINGS OF FACT 1. Throughout the appeal period, the Veteran's symptoms of adjustment disorder with depressed mood more nearly approximate occupational and social impairment with deficiencies in most areas; his symptoms do not more nearly approximate total occupational and social impairment. 2. Resolving all reasonable doubt in his favor, the Veteran's adjustment disorder with depressed mood renders him unable to secure or follow a substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for entitlement to an initial rating of 70 percent, but no higher, for adjustment disorder with depressed mood have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1-4.14, 4.130, Diagnostic Code 9440. 2. The criteria for entitlement to a TDIU are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.3, 4.15, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from June 2004 to October 2004 and July 2007 to August 2008. He had active service in Southwest Asia from September 2007 to July 2008. This matter comes before the Board of Veterans' Appeals (BVA or Board) from June 2013 and October 2014 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). In September 2018, the Board remanded these claims for additional development. Increased Rating 1. Entitlement to an initial rating higher than 30 percent for adjustment disorder with depressed mood. Service connection for adjustment disorder with depressed mood was established by a June 2013 rating decision, at which time a 30 percent rating was assigned, effective July 2011. In May 2014, the Veteran disagreed with the rating assigned. Disability ratings are based on the average impairment of earning capacity resulting from disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. Where there is a question as to which of two evaluations shall be applied, the higher evaluations will be assigned if the disability more closely approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, when the question for consideration is entitlement to a higher initial rating assigned following the grant of service connection, evaluation of the medical evidence since the effective date of the grant of service connection and consideration of the appropriateness of "staged ratings" (assignment of different ratings for distinct periods of time, based on the facts found), is required. See Fenderson, 12 Vet. App. at 126. The Board has considered the entire record, including the Veteran's VA clinical records and private treatment records. These show complaints and treatment but will not be referenced in detail. The Federal Circuit has held that the Board must review the entire record but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000). Therefore, the Board will discuss the evidence pertinent to the rating criteria and the current disability. Under the General Formula for Mental Disorders (General Formula), the Board must conduct a "holistic analysis" that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). As noted, the Veteran is currently rated as 30 percent disabled due to his adjustment disorder with depressed mood. A 30 percent rating is assigned when symptoms such as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, or recent events), cause occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and normal conversation). A 50 percent rating is assigned when symptoms such as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; or difficulty in establishing and maintaining effective work and social relationships cause occupational and social impairment with reduced reliability and productivity. A 70 percent rating is assigned when symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; or memory loss for names of close relatives, own occupation or own name. The Veteran was afforded a VA examination in May 2013. The Veteran reported that he currently lived with his mother and brother in his grandmother's house but that he did not have a good relationship with his family and was often involved in arguments with them. He reported being married six months prior to getting divorced. The Veteran indicated that after discharge from the military, he worked as a contractor for approximately six months but left the job because of a disagreement with the supervisor. He then worked for a restaurant for approximately two months and was laid off because he did not report to work; he indicated he had been unemployed for the past two years. The Veteran reported outbursts of anger, stating that if someone startles him, he reacts by becoming very angry. He stated his mother made a loud "pop noise" that morning and he felt enraged but did not act on it and kept it inside. He reported daily feelings of depression, with a tendency to isolate himself. The Veteran indicated that he no longer socialized with friends, but generally remained in his room and watched television. He reported that in 2008 he was in a confrontation with a store clerk and shattered the glass door of the store. He was charged with destruction of property, but the assault charge was dropped. The examiner noted that the Veteran was oriented to person, time, and place and that he was casually dressed with appropriate hygiene. The examiner indicated that the Veteran kept rubbing his nose and constantly touched his face and neck throughout the interview; speech was appropriate for rate, but low for volume and at times it was not fluent due to mumbling. Eye contact was noted to be poor; mood and affect were depressed; however, the Veteran did not appear to have any perceptual disturbance, delusions, paranoia, or self-directed or other-directed violence. His thought process was organized and coherent. The Veteran had feelings of detachment from others and irritability or outbursts of anger. The Veteran submitted a Mental Health Symptoms checklist in April 2014. He endorsed the following symptoms: anger, anxiety, chronic sleep problems, depression, difficulty making decisions, drug abuse, emotion numbing, flashbacks, guilt, inability to keep and make friends, inappropriate behavior, intrusive thoughts, isolation, memory loss, neglect of personal hygiene, neglects family, nervousness, panic attacks, problems with communication, problems at work, problems getting along with people, sense of helplessness, substance abuse, suicidal thoughts/feelings, suspiciousness, unable to share feelings, and that he takes medication for his mental condition. In an April 2014 VA Form 21-8940, Veterans Application for Increased Compensation Based on Unemployability, the Veteran reported that he lost his job because he could not get along with management due to his psychiatric disability. A letter from a private healthcare provider, dated October 2014, indicates the Veteran suffers from deficiencies in most areas of his life. The nurse reported that although the Veteran is compliant with medication, he is not able to interact with others and deal with the normal stress of social interaction. It was noted that the Veteran is not able to initiate or maintain healthy, functional relationships with people; he takes offense easily to criticism and does not interpret constructive criticism as productive input. It was reported that the Veteran generally experiences high anxiety when dealing with people. The nurse also noted that the Veteran experiences deficiencies with his mood, experiencing depression daily. The Veteran lives with a high level of anxiety, he can become easily irritated when dealing with menial tasks and has become violent in the past when pressed. It was noted that the Veteran can become particularly upset when startled or dealing with conflict. The nurse reported that the Veteran isolates himself to his room to avoid stress and conflict at all costs and experiences continuous bouts of moderate anxiety, but his anxiety jumps to very high levels in any given situation. The nurse explained that during high levels of anxiety, the Veteran will either become furious and violent or he will break down; he has been known to damage walls and throw things during these bouts of anxiety. Concluding, the nurse indicated that because of his symptoms, the Veteran has been known to self-neglect and during deep depression, he will skip bathing for two weeks at a time. He is also not capable of maintaining a healthy sleep schedule due to reoccurring combat-related nightmares. The Veteran was afforded a VA examination in December 2015. He reported now living with his mother in an apartment, instead of living with his mother and brother in his grandmother's house. He reported moving out because the house was too crowded, and he did not get along with his grandparents. He reported a "so-so" relationship with his mother, but that she was always complaining about bills. The Veteran denied dating since his divorce in 2011; however, he indicated he had some friends and one good friend. He denied talking or hanging out with them often though and reported spending a lot of time in his room watching television. The Veteran reported that he "freaked out going to Food City" because the store was packed, and he had cold sweats. The Veteran reported seeing a psychiatrist once every three months, and a case manager once every two weeks. It was noted that he was on medication. He reported fleeting suicidal thoughts, but no plan or intent. The Veteran stated he does "not like to be around anyone, like to be in solitude, don't like to do anything, hate life period, would rather be buried in a grave than do anything. I don't exist." He reported being afraid if someone pushed him that he would go over the edge and harm someone, stating "I am scared of myself." Examination indicated he was alert and oriented, and dressed casually with appropriate hygiene. Speech was clear and coherent with regular rate, rhythm, and volume. Eye contact was appropriate, and his memory was intact. His reported mood was irritated; however, he showed no signs of irritation other than self-report. The Veteran also submitted private treatment records detailing his psychiatric treatment. The Veteran was often dressed appropriately and denied suicidal ideation or homicidal ideation, but frequently had a depressed or irritable mood during his appointments. The Board finds the Veteran exhibits symptoms that demonstrate occupational and social impairment with deficiencies in most areas, including unprovoked irritability, difficulty in adapting to stressful circumstances, and inability establishing and maintaining effective relationships. Overall, the Veteran's symptoms, particularly his irritability, lack of social activities, inability to maintain relationships, and periods of time where he neglects personal hygiene, more nearly approximate a 70 percent rating, throughout the period on appeal. The Board, however, does not find that the Veteran is entitled to a 100 percent disability rating because the evidence does not suggest he has total occupational and social impairment. The Board acknowledges that the Veteran has significant interference with his ability to work, which is reflected in the now assigned 70 percent rating. Moreover, the Board points out that the standards for the assignment of a TDIU are not the same as those for a 100 percent evaluation for a psychiatric disorder. While a TDIU may be warranted when a person is unable to follow a substantially gainful occupation, a 100 percent rating for a psychiatric disorder states that total occupational and social impairment is needed. 38 C.F.R. §§ 3.340, 4.130. In this case, the Veteran's symptoms have not been shown to be so severe that he has total social and occupational impairment. At no time has any VA examiner found this to be the case, and the Board finds that this is also not reflected in the Veteran's treatment records or his own personal statements. Although the Veteran has experienced severe symptoms throughout the appeal period, the record does not reflect total social impairment. He has not exhibited symptoms such as grossly inappropriate behavior, memory loss for his name or names of close relatives, or disorientation to time or place. He has reported suicidal thoughts, but there is no indication that the Veteran is in persistent danger of hurting himself or others. The Veteran has consistently been found to be oriented in all spheres with no reports of psychotic symptoms. The Board acknowledges that the Veteran isolates himself; however, the Veteran himself indicated that he has some friends and one good friend. He has also been able to maintain a "so-so" relationship with his mother and live in an apartment with her. Based on the entirety of this record, the Veteran's disability picture for his adjustment disorder with depressed mood most closely approximates the 70 percent disability rating because there is evidence of serious, but not total impairment. The Board has also considered the Veteran's symptoms which are not included in the rating criteria listed under 38 C.F.R. § 4.130 and whether they constitute symptoms that would be comparable in type and degree (frequency, severity, and duration) to the criteria for a 100 percent rating. See Mauerhan, 16 Vet. App. at 443; Vazquez-Claudio v. Shinseki. Though the Veteran's symptoms have been shown to be significant and manifest with frequency, the Board, in weighing all of the evidence, does not find that these symptoms are of a comparable severity to the symptomatology required for a rating of 100 percent. The Board notes that the lay assertions of the Veteran have been considered and are part of the reason why a 70 percent initial evaluation has now been assigned for the entire appeal period. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). To the extent that the Veteran may believe that a 100 percent evaluation is warranted, these assertions are outweighed by more probative evidence provided by the examinations of qualified medical professionals. See Jones v. Brown, 7 Vet. App. 134, 137-138 (1994). Furthermore, the symptoms described in the Veteran's lay statements are consistent with those noted in the treatment records and comport with the 70 percent rating that has now being assigned. As such, these lay statements do not provide any basis upon which to assign any higher rating. In sum, the Board finds that the Veteran's impairment due to his adjustment disorder with depressed mood has been most consistent with a 70 percent disability rating, but no higher, for the entire period on appeal. In reaching this conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. See Gilbert, 1 Vet. App. 49, 55 (1990); 38 U.S.C. § 5107 (b). 2. Entitlement to a TDIU. The Veteran seeks entitlement to a TDIU. A total disability rating may be assigned, where the schedular rating is less than total, when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as the result of service-connected disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 4.16. Consideration may be given to a Veteran's level of education, special training, and previous work experience in arriving at a conclusion, but not to his age or the impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19; see also Todd v. McDonald, 27 Vet. App. 79, 85-86 (2014). An award of TDIU does not require a showing of 100 percent unemployability. Roberson v. Principi, 251 F.3d 1378, 1385 (2001). The central inquiry is whether a Veteran's service-connected disabilities alone are of sufficient severity to render the Veteran unable to secure or follow a substantially gainful occupation. Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). To qualify for a TDIU, the evidence must show that the Veteran is unable to secure or follow a substantially gainful occupation as a result of his service-connected disabilities and there is one disability ratable at 60 percent or more, or, if more than one disability, at least one disability ratable at 40 percent or more and a combined disability rating of 70 percent. 38 C.F.R. § 4.16 (a). For the purpose of establishing one 60 percent disability, or one 40 percent disability in combination, disabilities affecting a single body system are considered as one disability. 38 C.F.R. § 4.16 (a)(3). Disabilities that are not service connected cannot serve as a basis for a total disability rating. 38 C.F.R. §§ 3.341, 4.19. A total disability rating may be assigned on an extraschedular basis, pursuant to the procedures set forth in 38 C.F.R. § 4.16 (b), for Veterans who are unemployable by reason of service-connected disabilities, but who fail to meet the percentage standards set forth in section 4.16(a). Unlike the regular disability rating schedule, which is based on the average work-related impairment caused by a disability, "entitlement to TDIU is based on an individual's particular circumstance." Rice v. Shinseki, 22 Vet. App. 447, 452 (2009) (quoting Thun v. Peake, 22 Vet. App. 111, 116 (2008)); see also Todd, 27 Vet. App. at 85-86. Therefore, in adjudicating a TDIU claim, VA must take into account the individual Veteran's education, training, and work history. Hatlestad v. Derwinski, 1 Vet. App. 164, 168 (1991). The Board emphasizes that the ultimate question of whether a Veteran is capable of substantially gainful employment is not a medical one; rather, that determination is for the adjudicator. Geib v. Shinseki, 733 F.3d 1350 (Fed. Cir. 2013). When there is an approximate balance of evidence for and against an issue, all reasonable doubt will be resolved in the Veteran's favor. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3; Gilbert, supra. The Veteran asserts that his psychiatric disability prevents him from obtaining and maintaining employment. He indicated that he was unable to maintain his last employment due to an inability to get along with management. See April 2014 Veteran's Application for Increased Compensation Based on Unemployability. As a result of this decision, from July 2011, the Veteran's rating is 70 percent for his adjustment disorder with depressed mood. Thus, the Veteran meets the schedular requirements for TDIU from this date forward. 38 C.F.R. § 4.16 (a). The Veteran completed four years of high school and obtained an additional two years of training in auto mechanics. See April 2014 VA 21-8940, Veteran's Application for Increased Compensation Based on Unemployability. During the May 2013 VA examination, the Veteran indicated that after discharge from the military, he worked as a contractor for approximately six months but left the job because of a disagreement with the supervisor. He then worked for a restaurant for approximately two months and was laid off because he did not report to work. Here, the evidence of record indicates that the Veteran is unemployable due to his service-connected adjustment disorder with depressed mood. The Board notes that even though the May 2013 and December 2015 VA examiners indicate the Veteran is employable, they both noted symptoms that impact the Veteran's employability. Specifically, both examiners indicated that the Veteran experiences a tendency to isolate, depressed mood, irritability, outbursts of anger, and detachment from others. Additionally, the November 2014 private nurse reported that the Veteran is not able to interact with others, takes offense easily to criticism and does not interpret constructive criticism as productive input. It was noted that he is easily irritated when dealing with menial tasks and has become violent in the past when pressed. The nurse explained that at high levels of anxiety, the Veteran either becomes furious and violent or he will break down; he has been known to damage walls and throw things during bouts of anxiety. Furthermore, during deep depressions, the Veteran neglects personal hygiene and will skip bathing for two weeks at a time and is unable to maintain a healthy sleep schedule. Based on the evidence of record, although the Veteran is likely able to physically obtain and maintain employment, the Board concludes that he is unable to perform the mental acts required for substantially gainful employment. The Board finds that a work environment would likely trigger the Veteran's psychiatric symptoms and not allow him to function successfully. The above discussion of the severity of his psychiatric symptoms combined with his educational and occupational experience, support a conclusion that the Veteran is unable to secure and follow substantially gainful employment as a result of his service-connected adjustment disorder with depressed mood, since July 28, 2011. Thus, a TDIU is warranted from July 28, 2011, when all the criteria for a TDIU are met. 38 C.F.R. § 4.16 (a). Prior to July 28, 2011, the Veteran was not yet service connected for his psychiatric disability or any other disability, and as such, a TDIU is not warranted prior to that date. REASONS FOR REMAND 3. Entitlement to service connection for hypertension, to include as secondary to service-connected adjustment disorder with depressive mood. The Veteran seeks entitlement to service connection for hypertension, to include as secondary to service-connected adjustment disorder with depressive mood. For VA purposes, the term hypertension means that the diastolic blood pressure is predominantly 90mm or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160mm or greater with a diastolic blood pressure of less than 90mm. 38 C.F.R. § 4.104 (Note (1) to Diagnostic Code 7101). Hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days. The Veteran's active problem list in VA treatment records does not contain a diagnosis of hypertension. The Board notes that the Veteran has an active problem of "elevated blood pressure reading without diagnosis of hypertension." See, e.g., March 2017 Active Problem List. However, there are multiple elevated blood pressure readings post service, including an April 2012 blood pressure reading of 141/95, January 2013 blood pressure reading of 136/99, July 2013 blood pressure reading of 130/94, October 2013 blood pressure reading of 143/100, January 2014 blood pressure reading of 143/100, a March 2014 blood pressure reading of 139/99, and a April 2014 blood pressure reading of 139/99. The Veteran was afforded a VA examination in October 2019. The Veteran's blood pressure was taken once and was noted to be 138/80. The examiner stated the Veteran does not have a formal diagnosis of hypertension and his blood pressure readings throughout service were within the normal range, citing the following blood pressure readings: August 2003 entrance examination blood pressure reading of 127/79, August 2009 blood pressure reading of 140/60, April 2018 blood pressure reading of 135/80 and January 2019 blood pressure reading of 132/64. The examiner failed to note or discuss the multiple post-service diastolic blood pressures that were 90mm or greater. On remand, an addendum opinion should be obtained to clarify whether the Veteran has a diagnosis of hypertension, to include discussion of the multiple post-service blood pressure readings with diastolic blood pressures 90mm or greater. 4. Entitlement to service connection for a bilateral knee disability. The Veteran seeks entitlement to service connection for a bilateral knee disability. The Veteran asserts that standing in a gun turret for hours at a time and wearing heavy equipment caused his knee injuries. He reports he now suffers from constant pain and has difficulty walking. A March 2009 VA treatment note states the Veteran reported right knee pain that started about six months into his last deployment and that he had a big bottle of ibuprofen and used it, figuring if he went to the medic that was all he would have. Less than a year after discharge from active service, a February 2009 National Guard record indicates the Veteran was on a temporary profile due to knee pain. In a January 2010 VA treatment note, the Veteran reported bilateral knee pain for the last four to five years, which would have placed the onset of pain in approximately 2004 or 2005. The Veteran was afforded a VA examination in October 2019, at which time the examiner opined that the Veteran's bilateral knee condition is less likely as not related to military since the Veteran's service treatment records are silent for any knee condition or injury. The examiner then noted that the Veteran's entrance exam was silent for any previous knee condition and the first complaint of bilateral knee pain was in October 2009. The examiner also stated there were no recent complaints of knee pain to the Veteran's VA primary care provider. An opinion based on the absence of in-service treatment without consideration of a Veteran's competent reports is inadequate. See Dalton v. Nicholson, 21 Vet. App. 23 (2007) (an examination must consider lay evidence of in-service incurrence or continuity of symptomatology since service). Here, the Veteran indicated that he self-treated his in-service symptoms and the examiner failed to note and discuss the Veteran's lay statements or the March 2009 VA treatment note reporting an onset of knee pain during service, a February 2009 temporary profile, and a January 2010 VA treatment note reporting an onset of bilateral knee pain during service. The Board finds an addendum opinion is necessary. 5. Entitlement to service connection for acid reflux, to include as secondary to adjustment disorder with depressed mood. The Veteran seeks entitlement to service connection for acid reflux. He asserts he began experiencing symptoms during service. The Veteran was afforded a VA examination in October 2019. The Veteran reported he was diagnosed in 2013 by a private physician but did not have an EGD testing. The Veteran indicated that he gets heartburn five times a week at night and when he wakes. He also reported similar episodes in the military and would take Zantac but did not seek medical care. The examiner indicated the Veteran had the following signs and symptoms due to an esophageal condition: infrequent episodes of epigastric distress, dysphagia, reflux, regurgitation, pain, and sleep disturbance caused by esophageal reflux. However, the examiner then stated that the Veteran does not have a formal diagnosis of reflux disease at this time and opined that the Veteran's condition is less likely as not related to military since the Veteran's service treatment records are silent for any acid reflux condition. The Board finds an addendum opinion is necessary that clarifies the Veteran's diagnosis and provides an opinion that considers and discusses the Veteran's lay statements regarding the onset and self-treatment of his symptoms during service. The matters are REMANDED for the following action: 1. Obtain and associate with the claims file all updated treatment records. 2. Obtain an addendum opinion for the Veteran's claimed hypertension. If deemed necessary by the examiner, afford the Veteran a VA examination. Based on a full review of the record, to include the Veteran's lay statements regarding the incurrence and symptomatology of the disorder, please answer the following: a) Please clarify the Veteran's diagnosis; the examiner should indicate whether the Veteran has a post-service diagnosis of hypertension. *The examiner must consider and discuss the multiple post-service blood pressure readings, to include, but not limited to: April 2012 blood pressure reading of 141/95; January 2013 blood pressure reading of 136/99; July 2013 blood pressure reading of 130/94; October 2013 blood pressure reading of 143/100; January 2014 blood pressure reading of 143/100; a March 2014 blood pressure reading of 139/99; and a April 2014 blood pressure reading of 139/99. b) If the Veteran has a diagnosis of hypertension, the examiner should opine as to whether it is at least as likely as not that: a. it had an onset during service, or is otherwise causally or etiologically due to service; or, b. is proximately due to or aggravated (beyond a natural progression) by his service-connected adjustment disorder with depressed mood. In so opining, the examiner should consider and discuss the medical article submitted by the Veteran in April 2016 regarding the relationship between anxiety and high blood pressure. A detailed explanation (rationale) is requested for all opinions provided, citing supporting clinical data and/or medical literature, as appropriate. If it is not possible to provide the requested opinions without resort to speculation, the examiner should explain why that is so. 3. Obtain an addendum opinion for the Veteran's claimed bilateral knee disability. If deemed necessary by the examiner, afford the Veteran a VA examination. Based on a full review of the record, to include the Veteran's lay statements regarding the incurrence and symptomatology of the disorder, please answer the following: a) For any knee disorder diagnosed, or functional impairment of the bilateral knees, please opine as to whether it is at least as likely as not (a 50 percent or greater probability) that such disorder/functional impairment had its onset during the Veteran's service or is causally or etiologically due to service, to include the reported onset of knee pain during service. b) In so opining, the examiner should consider and discuss the Veteran's theory that standing in a gun turret for hours at a time and wearing heavy equipment caused his knee injuries; a March 2009 VA treatment note stating the Veteran reported right knee pain that started about six months into his last deployment and that he had a big bottle of ibuprofen and used it, figuring if he went to the medic that was all he would have; a February 2009 National Guard record, less than a year after discharge from active service, indicating the Veteran was on a temporary profile due to knee pain; a January 2010 VA treatment note that indicates the Veteran reported bilateral knee pain for the last four to five years, which would have placed the onset of pain in approximately 2004/2005. A complete rationale should be given for all opinions and conclusions expressed. In the event the examiner cannot provide an opinion without resorting to speculation, it is essential that the examiner provide a rationale for this conclusion (e.g., lack of sufficient information/evidence, the limits of medical knowledge, etc.). 4. Obtain an addendum opinion for the Veteran's claimed acid reflux. If deemed necessary by the examiner, afford the Veteran a VA examination. Based on a full review of the record, to include the Veteran's lay statements regarding the incurrence and symptomatology of the disorder, please answer the following: a) Please clarify the Veteran's diagnosis; the examiner should indicate whether the Veteran has a post-service diagnosis of acid reflux or functional impairment related to acid reflux type symptoms, at any time during the course of the appeal. b) If the Veteran's symptoms cannot be attributed to a known clinical diagnosis, the examiner must indicate whether it is at least as likely as not (50 percent probability or greater) that the Veteran's symptoms are the result of an undiagnosed illness or medically unexplained chronic multi-symptom illness etiologically related to his service in Southwest Asia. c) For any acid reflux disorder diagnosed/functional impairment noted, please opine as to whether it is at least as likely as not (a 50 percent or greater probability) that such disorder/functional impairment had its onset during the Veteran's service or is causally or etiologically due to service, to include the reported onset of symptoms and self-treatment during service. A complete rationale should be given for all opinions and conclusions expressed. In the event the examiner cannot provide an opinion without resorting to speculation, it is essential that the examiner provide a rationale for this conclusion (e.g., lack of sufficient information/evidence, the limits of medical knowledge, etc.). TANYA SMITH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board L. Andersen, 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.