Citation Nr: 22015663 Decision Date: 03/18/22 Archive Date: 03/18/22 DOCKET NO. 18-55 514 DATE: March 18, 2022 REMANDED Entitlement to service connection for heart disease is remanded. Entitlement to service connection for hypertension is remanded. Entitlement to service connection for a prostate disability is remanded. Entitlement to service connection for rheumatoid arthritis, claimed as skeletal arthritis of the entire joint system, is remanded. Entitlement to service connection for a headache disorder, to include as secondary to rheumatoid arthritis, is remanded. Entitlement to service connection for a low back disability, to include degenerative joint disease and as secondary to rheumatoid arthritis, is remanded. Entitlement to service connection for a right hip disability, to include cox valga and as secondary to rheumatoid arthritis, is remanded. Entitlement to service connection for a left hip disability, to include cox valga and as secondary to rheumatoid arthritis, is remanded. Entitlement to service connection for a right knee disability, to include as secondary to rheumatoid arthritis, is remanded. Entitlement to service connection for a left knee disability, to include as secondary to rheumatoid arthritis, is remanded. Entitlement to service connection for a right foot disability, to include as secondary to rheumatoid arthritis, is remanded. Entitlement to service connection for a left foot disability, to include as secondary to rheumatoid arthritis, is remanded. REASONS FOR REMAND The Veteran had active service from May 1965 to November 1968. These matters come before the Board of Veterans' Appeals (Board) on appeal from a September 2018 rating decision of a Department of Veterans Affairs (VA) regional office (RO). In November 2021, the Veteran testified at a virtual hearing held before the undersigned Veterans Law Judge and a transcript of that hearing has been associated with the electronic claims file. The undersigned Veterans Law Judge agreed to hold the record open for 90 days. Hearing transcript, page 2. That 90-day period has expired. 38 C.F.R. § 20.605 (2021). The Veteran underwent treatment at the Houston VA Medical Center in August 2019. The RO last looked for records at that facility in April 2018. The RO should obtain all records from that facility from April 2018 to the present. Private treatment records reflect that the Veteran's previous rheumatologist was Dr. Joshi. At the hearing, the Veteran testified that his heart disease was diagnosed by Drs. Ozinkawski and Rotenberg and that Dr. Rotenberg is still treating him. Hearing transcript, page 6. The RO last obtained records from Dr. Rotenberg in September 2018. The RO should obtain records from these providers. The Veteran's service treatment records reveal elevated blood pressure readings on an August 1966 remote tour physical examination and an October 1968 separation examination. A VA examination is necessary to determine whether the Veteran's hypertension and heart disease are related to active service. The Veteran asserts that he had headaches, joint pain, and frequent urination in service. The Veteran denied these symptoms on his separation examination. He, however, testified that these symptoms that he would not have gone to sick call for treatment. Id. at 7-13. In other words, the Veteran testified that these symptoms were not symptoms he would have reported to medical professionals. The Veteran is competent to report these symptoms and, given the Veteran's explanation about not reporting them, the Board finds him credible. VA examinations are necessary to determine whether the orthopedic disorders, any headache disorder, and prostate disorder are related to active service. An inquiry with the Social Security Administration shows that the Veteran had title II status. The RO should ask the Veteran whether he has ever applied for Social Security disability benefits and obtain any records pertaining to any claims. The matters are REMANDED for the following action: 1. Ask the Veteran to identify all treatment for hypertension, heart disease, his prostate disability, headaches, rheumatoid arthritis, his low back disability, his hip disabilities, his knee disabilities, and his foot disabilities from November 1968 to the present. Obtain any identified records. Obtain the Veteran's VA treatment records from the Houston VA Medical Center for the period from April 2018 to the present. Ask the Veteran to complete a VA Form 21-4142 for Drs. Joshi, Ozinkawski, and Rotenberg. Make two requests for the authorized records from Drs. Joshi, Ozinkawski, and Rotenberg, unless it is clear after the first request that a second request would be futile. 2. Ask the Veteran whether he has ever applied for Social Security disability benefits. Depending on his response, obtain the Veteran's federal records from the Social Security Administration pertaining to any claim for disability benefits. Document all requests for information as well as all responses in the claims file. 3. After the development in 1 and 2 is completed, schedule the Veteran for an examination by an appropriate clinician to determine the natures and etiologies of hypertension and heart disease. The examiner must opine whether it is at least as likely as not that hypertension is related to an in-service injury, event, or disease, including the elevated blood pressure readings on the August 1966 remote tour physical examination and the October 1968 separation examination. The clinician must opine on whether it is at least as likely as not that hypertension (1) began during active duty, (2) manifested within one year after discharge from service in November 1968, or (3) was noted during service with continuity of the same symptomatology of possible cardiac symptomatology shortness of breath, numbness and pain in arms, chest pain, headaches, and lightheadedness since service. The examiner must opine whether it is at least as likely as not that heart disease is related to an in-service injury, event, or disease, including the elevated blood pressure readings on the August 1966 remote tour physical examination and the October 1968 separation examination. The clinician must opine on whether it is at least as likely as not that the heart disease (1) began during active duty, (2) manifested within one year after discharge from service in November 1968, or (3) was noted during service with continuity of the same symptomatology of possible cardiac symptomatology continuity of the same symptomatology of possible cardiac symptomatology shortness of breath, numbness and pain in arms, chest pain, headaches, and lightheadedness since service. 4. After the development in 1 and 2 is completed, schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of his prostate disability. The examiner must opine whether it is at least as likely as not that the prostate disability is related to an in-service injury, event, or disease, including in-service frequent urination. 5. After the development in 1 and 2 is completed, schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of his headache disorder. The examiner must opine whether it is at least as likely as not that the headache disorder is related to an in-service injury, event, or disease, including the elevated blood pressure readings on the August 1966 remote tour physical examination and the October 1968 separation examination and in-service headaches. The examiner must opine on whether it is at least as likely as not that the headache disorder was (1) caused by or (2) aggravated by rheumatoid arthritis. If the examiner finds that the headache disorder was aggravated by the service-connected rheumatoid arthritis, then the medical professional should quantify the degree of aggravation. 6. After the development in 1 and 2 is completed, schedule the Veteran for an examination by an appropriate clinician to determine the natures and etiologies of his rheumatoid arthritis, low back disability, hip disabilities, knee disabilities, and foot disabilities. The examiner must opine whether it is at least as likely as not that the rheumatoid arthritis is related to an in-service injury, event, or disease, including in-service joint pain. The clinician must opine on whether it is at least as likely as not that the rheumatoid arthritis (1) began during active duty, (2) manifested within one year after discharge from service in November 1968, or (3) was noted during service with continuity of the same symptomatology of joint pain since service. The examiner must opine whether it is at least as likely as not that the low back disability is related to an in-service injury, event, or disease, including in-service joint pain. For arthritis of the lumbar spine, the clinician must opine on whether it is at least as likely as not that the arthritis (1) began during active duty, (2) manifested within one year after discharge from service in November 1968, or (3) was noted during service with continuity of the same symptomatology of joint pain since service. The examiner must opine on whether it is at least as likely as not that any current lumbar spine disability was (1) caused by or (2) aggravated by rheumatoid arthritis. If the examiner finds that a current lumbar spine disability was aggravated by the service-connected rheumatoid arthritis, then the medical professional should quantify the degree of aggravation. The examiner must opine whether it is at least as likely as not that any current disability of either hip, to include bilateral cox valga, is related to an in-service injury, event, or disease, including the right hip laceration in October 1966 and in-service joint pain. For any arthritis of either hip, the clinician must opine on whether it is at least as likely as not that the arthritis (1) began during active duty, (2) manifested within one year after discharge from service in November 1968, or (3) was noted during service with continuity of the same symptomatology of joint pain since service. The examiner must opine on whether it is at least as likely as not that any current disability of either hip, to include bilateral cox valga, was (1) caused by or (2) aggravated by rheumatoid arthritis. If the examiner finds that a current hip disability was aggravated by the service-connected rheumatoid arthritis, then the medical professional should quantify the degree of aggravation. The examiner must opine whether it is at least as likely as not that any current disability of either knee is related to an in-service injury, event, or disease, including in-service joint pain. For any arthritis of either knee, the clinician must opine on whether it is at least as likely as not that the arthritis (1) began during active duty, (2) manifested within one year after discharge from service in November 1968, or (3) was noted during service with continuity of the same symptomatology of joint pain since service. The examiner must opine on whether it is at least as likely as not that any current disability of either knee was (1) caused by or (2) aggravated by rheumatoid arthritis. If the examiner finds that a current knee disability was aggravated by the service-connected rheumatoid arthritis, then the medical professional should quantify the degree of aggravation. The examiner must opine whether it is at least as likely as not that any current disability of either foot is related to an in-service injury, event, or disease, including in-service joint pain. For any arthritis of either foot, the clinician must opine on whether it is at least as likely as not that the arthritis (1) began during active duty, (2) manifested within one year after discharge from service in November 1968, or (3) was noted during service with continuity of the same symptomatology of joint pain since service. The examiner must opine on whether it is at least as likely as not that any current disability of either foot was (1) caused by or (2) aggravated by rheumatoid arthritis. If the examiner finds that a current foot disability was aggravated by the service-connected rheumatoid arthritis, then the medical professional should quantify the degree of aggravation. 7. After development above has been completed, the RO should readjudicate the Veteran's claims with consideration of all evidence of record. If any claim remains denied, the Veteran should be issued a supplemental statement of the case, with a copy to his agent, and afforded an opportunity to respond. MICHAEL LANE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Cherry, 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.