Citation Nr: 22015114 Decision Date: 03/16/22 Archive Date: 03/16/22 DOCKET NO. 20-17 440 DATE: March 16, 2022 REMANDED Entitlement to a rating in excess of 30 percent for posttraumatic stress disorder (PTSD) is remanded. Entitlement to service connection for left wrist disability is remanded. Entitlement to service connection for left knee disability is remanded. Entitlement to service connection for hypertension, to include as due to herbicide exposure, is remanded. Entitlement to service connection for erectile dysfunction, to include as secondary to hypertension, is remanded. REASONS FOR REMAND The Veteran served on active duty from March 1966 to February 1969, including service in Vietnam. This matter is on appeal before the Board of Veterans Appeals (Board) from a May 2017 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). 1. Entitlement to a rating in excess of 30 percent for PTSD. The Veteran most recently underwent a VA contract examination to assess the current severity of his PTSD in April 2017. In a January 2022 brief, the Veteran's representative indicated that the Veteran has reported that his PTSD has worsened since that examination. Given the assertion of worsening, the Veteran should be afforded an updated examination. 2. Entitlement to service connection for left wrist disability. 3. Entitlement to service connection for left knee arthritis. On his April 2020 Form 9, the Veteran reported that he was wounded in the left wrist and the left knee during his Vietnam service as a radio operator in the area of Hill 63. The service treatment records do not show an indication of such injuries. However, on the Form 9, the Veteran indicated that service treatment records pertaining to his time in Vietnam were lost after he left the country and returned to his duty station in Germany. The Board notes that the service treatment records associated with the claims file do not appear to include any documentation pertaining to the time frame the Veteran was stationed in Vietnam (i.e. from approximately November 1966 to June 1968). Also, in June 2017, the Veteran submitted a copy of a handwritten letter dated from January 1968 from his superior, indicating that the Veteran had been released from his light duty as Battalion Draftsman and would be returning to the Hill 63 duty with the 101 Long Range Reconnaissance Patrol that he had been performing prior to his being injured. Along with this letter, the Veteran submitted a copy of a January 1968 letter of appreciation from his superior (from the Headquarters and Headquarters Detachment of the 523rd Signal Battalion) praising him for outstanding assistance and support while serving as Battalion Draftsman during the period from October 1967 to January 1968. Although the January 1968 handwritten letter does not indicate the basis for the Veteran's light duty, it does tend to support his report of suffering some injury, and the Veteran is competent to report that his left wrist and knee were injured. Also, the service personnel records show that other than the interlude as a Draftsman during the time frame mentioned in the letter of appreciation, he served primarily as a Radio Relay and Carrier Attendant, an assignment which was known to expose servicemen in the field in Vietnam to significant hazard. Consequently, even though there is no specific record of knee or wrist injury during service associated with the claims file; given that there is some documentation of record consistent with injury occurring; given that the Veteran is competent to report injuries involving the left knee and left wrist, and given that he has also reported current left knee and wrist problems, including specific reporting concerning current left knee problems to VA medical personnel (See e.g. August 2015 VA primary care note, documenting the Veteran's report of worsening left knee pain for years and the presence of retained shrapnel in the knee); the Board finds that a VA examination to assess the likely etiology of any current left wrist and left knee disability is appropriate prior to final adjudication of these claims. 4. Entitlement to service connection for hypertension, to include as due to herbicide exposure, is remanded. 5. Entitlement to service connection for erectile dysfunction, to include as secondary to hypertension, is remanded. As the Veteran served in Vietnam, he is presumed to have been exposed to herbicides. Also, VA treatment records indicate treatment for high blood pressure with medication. See e.g. March 2017 VA primary care note, indicating that the Veteran was currently being treated for high blood pressure with amlodipine besylate and HCTZ 25/Triamterene. Hypertension is not one of the disabilities presumptively associated with exposure to herbicide agents under 38 C.F.R. § 3.309(e). However, the National Academy of Sciences Institute of Medicine (NAS) has found that "there is enough epidemiologic evidence to conclude that there is a positive association" between hypertension and herbicide exposure. See November 15, 2018 press release from NAS. In light of this finding, a medical examination is necessary to determine the likelihood that the Veteran's current hypertension has been caused by his presumed herbicide exposure. Additionally, in July 2018, a VA contract medical opinion was provided, indicating that the Veteran's hypertension was less likely than not caused by his service-connected PTSD. However, the clinician did not provide an opinion concerning the likelihood that the hypertension has been aggravated by the PTSD. On remand, if the opinion pertaining to the likelihood that the Veteran's current hypertension has been caused by his presumed herbicide exposure is not favorable, the clinician should also provide an opinion concerning the likelihood that the Veteran's hypertension has been aggravated by his PTSD. Concerning service connection for erectile dysfunction, in a June 2017 statement, the Veteran has asserted that this has been caused by the medication he takes for his hypertension. Consequently, the claim is inextricably intertwined with the claim for service connection for hypertension and must also be remanded. On remand, if service connection for hypertension is granted, a VA medical opinion concerning the likelihood that the medication the Veteran takes for hypertension has caused current erectile dysfunction should also be provided. Prior to arranging for the above development, any outstanding VA treatment records dated from March 2017 to the present should be obtained. The AOJ should also make appropriate efforts to obtain any private treatment records pertaining to the claimed disabilities, which are appropriately identified by the Veteran. The matters are REMANDED for the following action: 1. Obtain any outstanding VA treatment records dated from March 2017 to the present. 2. Ask the Veteran to identify any pertinent non-VA records of treatment for PTSD, left wrist, left knee, hypertension, and erectile dysfunction, and make appropriate attempts to obtain any such records. 3. After the development in #1 and #2 is completed, schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected PTSD. The claims file should be made available for review by the examiner in conjunction with the examination. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the disability under the rating criteria. 4. After the development in #1 and #2 is completed, schedule the Veteran for a VA examination to assess the likely etiology of any left wrist and left knee disability. Any indicated tests, to include radiological testing to confirm arthritis and/or the presence of foreign bodies, should be performed, if deemed necessary. The examiner must also review the claims file in conjunction with the examination. This review should include the service treatment records, the post-service VA treatment records, and any other information of record deemed pertinent. The examiner should specifically consider whether the Veteran has any retained shrapnel/foreign bodies in the left knee and/or left wrist, and whether the knee and/or wrist show any indication of current impairment consistent with shrapnel wounds or other injury during service. If a diagnosis cannot be provided for the Veteran's left knee or left wrist but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinions below. The examiner is asked to provide medical opinions in answer to the following questions: A) Is any current left knee disability at least as likely as not related to service? B) Is any current left wrist disability at least as likely as not related to service? For purposes of providing the above opinions, the examiner should assume for purposes of the opinion that the Veteran suffered some level of injury to the left knee and left wrist during his service in Vietnam, even though there is no documentation of such injuries contained in the service treatment records associated with the claims file. The examiner should explain the rationale for each opinion provided. 5. After the development in #1 and #2 is completed, schedule the Veteran for a VA examination for hypertension and erectile dysfunction by a qualified medical professional. The examiner must review the claims file in conjunction with the examination. A) The examiner should provide an opinion as to whether the Veteran's hypertension is at least as likely as not related to his herbicide exposure during service. The medical professional should also review the National Academy of Sciences (NAS) Institute of Medicine finding that "there is enough epidemiologic evidence to conclude that there is a positive association" between hypertension and herbicide exposure." See November 15, 2018 press release from NAS. B) Is it at least as likely as not that the Veteran's hypertension has been aggravated by his service-connected PTSD? C) Is it at least as likely as not that any current erectile dysfunction has been caused by the medication the Veteran takes for hypertension? D) Is it at least as likely as not that any current erectile dysfunction has been aggravated by the medication the Veteran takes for hypertension? If aggravation is found, the examiner should identify to the extent possible the baseline level of disability prior to the aggravation and determine what degree of additional impairment is attributable to the service-connected disability. The examiner should explain the rationale for each opinion provided. S. HENEKS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Dan Brook, 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.