Citation Nr: 22018579 Decision Date: 03/29/22 Archive Date: 03/29/22 DOCKET NO. 16-00 222A DATE: March 29, 2022 ISSUES 1. Entitlement to service connection for a right foot disability, claimed as right foot arch trauma. 2. Entitlement to service connection for hypertension. 3. Entitlement to service connection for a cerebrovascular accident, claimed as secondary to hypertension. REMANDED Entitlement to service connection for a right foot disability, claimed as right foot arch trauma is remanded. Entitlement to service connection for hypertension is remanded. Entitlement to service connection for a cerebrovascular accident, claimed as secondary to hypertension is remanded. REASONS FOR REMAND The Veteran served on active duty from December 1976 to December 1978. This matter is before the Board of Veterans Appeals (Board) on appeal from an April 2014 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in New Orleans, Louisiana. An October 2017 rating decision granted service connection for lumbosacral strain, degenerative joint disease, degenerative disc disease of the lumbar spine, claimed as lower back strain. Next, the Veteran testified before the undersigned Veterans Law Judge (VLJ) in August 2018. A copy of the hearing transcript has been associated with the claims file. In March 2019, the Board remanded the issues for additional development. A May 2019 rating decision granted service connection for left and right great toe ingrown toenail removal residuals, in addition to special monthly compensation (SMC). Significantly, a March 2020 Board decision denied the service connection issues on appeal. Later, a February 2021 Order from the United States Court of Appeals for Veterans Claims (Court) granted a February 2021 Joint Motion for Remand (JMR) with respect to these issues currently before the Board. Appeals counsel submitted a Rule 33 Summary of Issues (Brief). Appeals counsel called for remands for additional development based upon allegedly inadequate VA examinations relied upon in the prior Board decision. For all issues, the Board observes that the February 2021 Brief begins with a discussion of the duty to assist. It reads in the first line, "First, the Board clearly erred when it failed to ensure that VA obtained an adequate VA exam to determine the nature of the Appellant's right foot condition." Counsel raises similar arguments for other issues on pages 5 and 6. As a threshold consideration, the February 2020 Informal Hearing Presentation (IHP) from one year earlier is devoid of any requests for imaging, new VA examinations, or other challenges based upon the duty to assist. In fact, it largely relies on a consideration of lay evidence, "The Veteran highlighted that August 1978 STRs are consistent with his lay history." There is no discussion of x-rays, as raised by appeals counsel only after the Board decision. The Board had carefully considered the hearing testimony and IHP, highlighting: The Veteran in this case has not referred to any deficiencies in either the duties to notify or assist; therefore, the Board may proceed to the merits of the claim. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015, cert denied, U.S.C. Oct. 3, 2016) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board....to search the record and address procedural arguments when the [appellant] fails to raise them before the Board"); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to an appellant's failure to raise a duty to assist argument before the Board). Nevertheless, pursuant to the JMR, the Court vacated the prior Board decision with respect to these three issues and remanded the matters for additional development. The Board then remanded these matters in July 2021in line with the JMR. Recently, the Veteran through his representative submitted a February 2022 Informal Hearing Presentation (IHP). In the IHP, the Veteran's representative begins by outlining the history of the JMR and the Board's compliance with the remand directives. After discussing the evidence for each issue, there is a lengthy paragraph alleging errors by VA in failing to provide adequate examinations. There are detailed citations in each of these paragraphs, incorporating various aspects of caselaw for adequate examinations and developing claims. For example, regarding hypertension and a cerebrovascular accident, the IHP reads: The VA erred when it failed to ensure to provide an adequate examination. When VA undertakes to provide a medical examination, it "must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided." Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). An examination is adequate where it is "based upon consideration of the veteran's prior medical history and examinations and also describes the disability, if any, in sufficient detail so that the Board's 'evaluation of the claimed disability will be a fully informed one.'" Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007) (quoting Ardison v. Brown, 6 Vet. App. 405, 407 (1994)). In addition, it must "sufficiently inform the Board of a medical expert's judgment on a medical question and the essential rationale for that opinion." Monzingo v. Shinseki, 26 Vet. App. 97, 105 (2012). The Veteran through his representative goes on to cite a quotation regarding a remand when there is a need for further evidence, clarification of evidence, or correction of a procedural defect. In light of the Veteran and his representative's repeated contentions, a remand for supplemental VA examinations is warranted. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. We discuss this with respect to each issue below. 1. Entitlement to service connection for a right foot disability, claimed as right foot arch trauma is remanded. The Board incorporates its discussion from the sections above by reference. By way of background, a Service Treatment Record (STR) from after August 3, 1978, but before August 28, 1978 for an unrelated matter shows notations of glass in the arch of the right foot. It was painful upon palpitation. A probe was done but the glass could not be removed. The December 1978 Report of Medical Examination from separation disclosed a clinically normal evaluation of the feet, upper extremities, lower extremities, and spine, other musculoskeletal system. The Veteran perfected his appeals in January 2016. Related to the right foot, the VA Form 9 shows that the Veteran has chronic pain in his foot because of the stress on his arch. There was constant running and marching in service. This is chronically painful. At the August 2018 hearing, the Veteran provided additional lay evidence regarding a foot that allegedly has glass in it that was difficult to remove. He has had pain when walking on something uneven that hits the glass and presses it in. He has experienced this pain in the right foot continuously since service. Specifically, the Veteran explained: There was pain every time I walked. And I went to sick bay, and they actually dug into my foot and they said that there was a piece of glass in there, but every time they tried to grab it, that they couldn't get it. But they made -- I have the paperwork here for that. But they said that every time that, you know -- they ended up making a 2- inch by 11/4-inch incision. I had it right here -- here. Yes, sir, up at the top. See August 2018 Hearing Transcript, p. 11. The Veteran highlighted that August 1978 STRs are consistent with his lay history. Next, the December 2019 VA 646 Statement of Accredited Representative in Appealed Case contains additional argument. For the right foot, it shows: The veteran contends that he should be entitled to service connection for a right foot disability. The veteran stated he did not have the condition at EAD. He stated that he had a "high arch" and was fitted for "combat" boots in the USMC. The veteran continued, "I was not provided with inserts or arch supports. After a period of time, I have chronic pain in my foot because of the stress on my unsupported arch. The constant running and marching only served to aggravate my condition. My arch has fallen to some degree and is chronically painful." Next, the Veteran was afforded an October 2019 VA foot examination with medical opinion. The VA examiner reviewed the entire claims file, and performed a physical examination. The VA examiner remarked, "The Veteran's exam today is normal, and he denies any pain on exam." However, it later shows that the Veteran reports pain in the right foot only when weight is applied. It shows, "It's 4/10 and it is a sharp pain, but it only happens when it hits the right spot." The VA examiner went on to render a negative nexus opinion. The VA examiner reasoned: During service, condition was acute only. There is no evidence of chronicity of care. There is objective evidence in his c-file of a complaint of right foot pain on 5/9/1978 after stepping on a piece of glass 2 days prior. The note states that no glass was noted. He was seen again in 8/1978 and it was noted that the glass was too deep to remove. His c-file is silent for any further objective evidence of a complaint of or treatment for right foot pain. There is objective evidence in the c-file of only two medical visit notes (on 5/9/1978 & 8/1978), and the c-file is then silent for a complaint of right foot pain until today's visit on 10/21/2019. Since there has been a gap of 42 years between when he sought care in the service and his claim now, and the objective evidence on physical exam was normal, and no diagnosis rendered, the claimed condition was less likely than not (less than 50 percent probability) incurred in or is otherwise related to the Veteran's active military service. Additional VA treatment records are substantially the same. They also show diabetic foot care. Next, the Board has considered appeals counsel's contentions in the February 2021 Brief as they relate to the February 2021 Joint Motion for Remand (JMR). First, the JMR shows that the VA examiner did not discuss whether the Veteran still had glass in his foot. See February 2021 JMR, p. 3. On the top of page 4, the JMR shows that a new VA examination should be obtained "in which the examiner conducts necessary testing and addressees whether there are any residual symptoms due to any glass remaining in Appellant's right foot." Id. at p 4. The February 2021 Brief goes on to discuss the need for a new VA examination that includes diagnostic studies including imaging studies such as x-rays. The insinuation that a VA examination should include imaging studies to render it adequate is novel. In this case, it is not certain that x-rays would conclusively establish the composition of a foreign object through the skin or otherwise provide for a more informed nexus opinion than already of record. Given the facts, a probe or endoscopy could be necessary in light of appeals counsel's request to determine the presence of any glass in the foot. Employing a less invasive approach, the October 2019 VA examiner already considered the Veteran's lay statements and the STRs in rendering a nexus opinion. Based upon this request now leading to a JMR, the Board ultimately remanded this issue in July 2021. Pursuant to appeals counsel's request, diagnostic studies, including but not limited to a probe or endoscopy should be conducted, to the extent possible. This was to be at the discretion of the VA examiner if the x-rays suggested in the February 2021 Brief would not be determinative in identifying the presence of glass in the right foot. See 38 U.S.C. § 5103A (d); McLendon v. Nicholson, 20 Vet. App. 79 (2006). Months later, the Veteran was afforded a November 2021 with VA medical opinion. The VA examiner elicited a lay history from the Veteran, reviewed the entire claims file, and performed a physical examination. The VA examiner cited diagnostic testing performed in 2005 and 2010 showing no foreign bodies. The VA examiner wrote, "No findings of foreign bodies in the right foot noted on x-rays done on 12/1/2006 or 3/22/2010. There is noted heel spurring on right from x-ray on 3/22/2010." The VA examiner documented a lay history in the remarks: Veteran states that there is intermittent sharp pain that only last a few seconds when he walks on uneven terrain. States that he feels this is over the area where glass was imbedded in his foot. On physical exam today there is no complaints of pain or discomfort with palpation of the foot and not pain with weight bearing or dorsiflexion. Next, the VA examiner rendered a negative nexus opinion for any right foot disability. The Board observes medical opinions are all located in the same combined document. The VA examiner concludes in part, "8. There is no diagnostic evidence found in the medical record that glass articles remain in the foot that are causing the pain and discomfort. Given this, I am unbale to establish a chronic condition that was caused by the glass in the foot in service in Aug 1978." Significantly, in the February 2022 IHP, the Veteran through his representative challenges the adequacy of the examination and VA's overall fulfilment of its duty to assist. The contentions begin with, "The VA erred when it did not provide an adequate statement of reasons or bases by not accounting for the evidence which it finds to be persuasive or unpersuasive. See Caluza v. Brown, 7 Vet. App. 498, 506 (1995)." As discussed above, there are additional lengthy allegations regarding adequate examinations. However, there are no specific claims of inadequacy with respect to the evidence that has been developed for the alleged right foot disability. In other words, the Veteran through his representative fails to identify a shortcoming of this recent examination. The Board is left to consider the general law cited in the IHP and bases for the JMR in reviewing the evidence of record. The Veteran is competent to provide evidence of that which he experiences, including his symptomatology and medical history. Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Veteran is competent to report pain in the arches of the right foot following running and marching in service. He is competent to report receiving treatment for glass in the right foot in service. The Veteran is also competent to relate what he has been told by a professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). First, the Veteran reported pain in the right foot at the November 2021 VA examination. The Board is mindful of the law governing pain. Evidence of pain alone which results in functional impairment, even if there is no identified underlying diagnosis, can constitute a disability. Saunders v. Wilkie, 886 F.3d 1356 (2018). Second, the recent VA examination does not include any contemporaneous diagnostic testing. Although such may be futile, i.e., only confirm what previous negative imaging already has, this was part of the basis for the JMR. The Board's July 2021 Remand directives required that any necessary diagnostic testing be performed, including a probe or other diagnostic technique, albeit at the discretion of the examiner. In light of the JMR, the Board will once again remand this issue for a new VA examination with medical opinion. Pursuant to appeals counsel's request, diagnostic studies, including but not limited to a probe or endoscopy should be conducted, to the extent possible. This will be at the discretion of the VA examiner if the x-rays suggested in the February 2021 Brief would not be determinative with respect to the presence of any glass in the right foot. If the Veteran does not wish to undergo any additional diagnostic testing or fails to report to the scheduled examination, the case will be adjudicated based upon the evidence of record. The Veteran and his representative are invited to submit any private medical opinions to assist VA in developing this claim. Therefore, the issue is remanded. 38 U.S.C. § 5103A (d); McLendon v. Nicholson, 20 Vet. App. 79 (2006). 2. Entitlement to service connection for hypertension is remanded. 3. Entitlement to service connection for a cerebrovascular accident, claimed as secondary to hypertension is remanded. The Board incorporates its discussion from the sections above by reference. The Board incorporates its discussion from the sections above by reference. A remand is necessary for additional development. We note that hypertension as cardiovascular-renal disease, is a recognized chronic disease, and as such, additional presumptive theories of entitlement are relevant in addition to direct service connection. See 38 C.F.R. §§ 3.303, 3.307, 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). "Hypertension" refers to persistently high arterial blood pressure. Medical authorities have suggested various thresholds ranging from 140 mm Hg systolic and 90 mm Hg diastolic to as high as 200 mm Hg systolic and 110 mm Hg diastolic as reflective of hypertension. See Dorland's Illustrated Medical Dictionary, 896 (32nd ed. 2012). Similarly, for VA rating purposes, the term "hypertension" means that the diastolic blood pressure is predominantly 90 mm Hg or greater. The term "isolated systolic hypertension" means that the systolic blood pressure is predominantly 160 mm Hg or greater with a diastolic blood pressure of less than 90 mm Hg. See 38 C.F.R. § 4.104, DC 7101, Note (1). For VA purposes, hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days. Id. Under DC 7101, a Veteran is entitled to a minimum compensable rating for hypertension when there is a "history of diastolic pressure predominantly 100 or more [that] requires continuous medication for control." 38 C.F.R. § 4.104, DC 7101. The M21-1 provides that "if current predominant blood pressure readings are non-compensable, a 10 percent evaluation may be assigned if... continuous medication is required for blood pressure control, and... past diastolic pressure (before medication was prescribed) was predominantly 100 or greater." M21-1, pt. V, sbpt. Iii, ch. 5 sec 3.b. Recently, in Wilson v. McDonough, No. 19-6020, the United States Court of Appeals for Veterans Claims (Court) held that the plain language of DC 7101 directs VA to consider historical, rather than current, blood pressure readings and that the relevant "historical blood pressure readings" are those taken before the Veteran began medication. The Court reasoned that DC 7101 provides three avenues to obtain a 10 percent rating: (1) diastolic pressure predominantly 100 or more; (2) systolic pressure predominantly 160 or more; or (3) a history of diastolic pressure predominantly 100 or more requiring continuous medication for control. Thus, the Board's interpretation of prong (3) requiring diastolic pressure readings of predominantly 100 or more during the current appeal period would render that prong extraneous, effectively collapsing it into the first prong. With respect to the claim for service connection for cerebrovascular accident (stroke), the Veteran's theory of entitlement is one of secondary service connection. Except as provided in § 3.300(c), disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310 (a). Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. 38 C.F.R. § 3.310 (b). By way of evidentiary history, the December 1978 Report of Medical Examination from separation disclosed a clinically normal evaluation of the heart and vascular system. Decades later, a February 2014 VA Form 21-0960C-8, Headaches Disability Benefits Questionnaire (DBQ), shows that the Veteran had headaches continuously since 1977 while stationed at Camp Pendleton. The Veteran suffered a stroke in 2009. Shortly thereafter, an April 11, 2014 VAMC Other Output / Reports includes an April 13, 2004 VA primary care note. It shows in part, "HTN for 7 yrs or circa 1997. Prior use of Procardia and Avapro with some dizziness, with elevated BP as the culprit." An October 23, 2015 VA Cardiology Note from the New Orleans VA Medical Center (VAMC) shows that the Veteran suffered a stroke twice in August 2009. It also shows a diagnosis for hypertension. Next, with respect to the hypertension claim, in the January 2016 VA Form 9, the Veteran explained his theory of entitlement. He asserted, "It is my contention (supported by my STRs) that I had elevated blood pressure on active duty. I now have full blown hypertension. This condition should be rated S/C." For a cerebrovascular accident, the January 2016 VA Form 9 shows in part, "This issue can only be rated a S/C if the hypertension (item #1) is rated S/C. We ask that the hypertension and the resultant CVA be rated as S/C." At the August 2018 hearing, the Veteran's representative highlighted that blood pressure readings in service were higher than normal, and constituted, "pre-hypertensive readings." The Veteran consistently testified that he would have his blood pressure taken several times in service because he was always nervous, until treatment providers got a normal reading. In other words, his numerous readings still showed essential hypertension even though they weren't recorded. The Veteran testified that he could not recall the exact year when he was diagnosed with hypertension. He concluded, "But, yes, it had been years before they finally I finally saw someone that told me you have hypertension and prescribed medication for me." See August 2018 Hearing Transcript, p. 5. Regarding a cardiovascular accident, the Veteran's representative testified, "He does think that service connection for stroke as a secondary would be appropriate because his doctor told him that his high blood pressure was a contributing factor to the stroke." See August 2018 Hearing Transcript, p. 14. The Veteran testified that he suffered from strokes in 2009. Next, the Veteran was afforded an October 2019 VA hypertension examination with medical opinion. The VA examiner elicited a lay history from the Veteran, reviewed the entire claims file, and performed a physical examination. The VA examiner identified hypertension, with a date of onset of 1997. The Veteran's own lay history placed the date of onset to 2004. "He states that around 2004 he was going for a routine medical visit and was told he had high blood pressure." It then shows, "He had two CVAs in 2009. He denies any other symptoms related to the hypertension." The VA examiner provided a medical history of hypertension: It is unknown if the Veteran's HTN was confirmed by taking BP readings 2 or more times on at least 3 different days. However, there is ample objective evidence in the Veteran's c-file of a diagnosis of and treatment for HTN since 4/13/2014. In a primary care note dated 4/13/2004, the provider, P. H., NP, notes that the Veteran was diagnosed with HTN in 1997. Next, the VA examiner rendered a negative nexus opinion for hypertension. The VA examiner described: The Veteran's C-file is silent for a diagnosis of HTN in service. Entrance exam on 4/23/1975 noted a BP of 132/86, physicals on 12/17/1976 noted a BP of 128/78, on 10/3/1977 noted a BP of 120/80, on 12/5/1975 noted a BP of 130/82, and a discharge exam on 12/8/1978 noted a BP of 118/70. On a primary care note dated 4/13/2004, the provider noted that the Veteran was diagnosed with HTN in 1997. A nexus has not been established. Related to the claim for service connection for a cardiovascular accident (CVA), the Veteran was also afforded an October 2019 VA nervous system and neuromuscular diseases examination. Right cerebellar ischemic stroke was identified from 2009. The VA examiner also rendered a negative nexus opinion for the cerebrovascular accident (stroke). The VA examiner reasoned: There is objective evidence in the Veteran's c-file of BP readings while in service ranging from 118-132 systolic and 70-86 diastolic. Specifically, the entrance exam on 4/23/1975 noted a BP of 132/86, physicals on 12/17/1976 noted a BP of 128/78, on 10/3/1977 noted a BP of 120/80, and on 12/5/1975 noted a BP of 130/82. His discharge exam on 12/8/1978 also noted a normal BP reading of 118/70. On a primary care note dated 4/13/2004, the provider noted that the Veteran was diagnosed with hypertension in 1997. The Veteran has other risk factors such as hyperlipidemia, obesity, CAD with CABG in 2007, obstructive sleep apnea and diabetes mellitus type II that could have contributed to his CVA. A nexus has not been established. Next, the December 2019 VA 646 Statement of Accredited Representative in Appealed Case contains additional argument. It shows: The veteran is appealing the April 24, 2014 Rating Decision of the VA Regional Office (RO) New Orleans, LA. A Timely Notice of Disagreement (NOD) and Substantive Appeal are of record. Thus, the veteran has filed a timely appeal on the issue under consideration. The veteran's appeal was remanded by the Board of Veterans' Appeals. The veteran was diagnosed with hypertension in 1997. He contends that service connection should be granted for this condition because "while on active duty whenever my blood pressure was taken it was normally taken four to six times prior to being recorded. It was explained to me that I might be suffering from 'white coat syndrome.' It wasn't until I was perfectly calm that the readings were taken and recorded. It is my contention that I had elevated blood pressure on active duty. I now have full-blown hypertension." . . . . The veteran contends that cerebrovascular accident (also claimed as stroke) should be granted service connection secondary to his hypertension. He feels that the hypertension ultimately caused the CVA and therefore both should be entitled to service-connection. Later, the February 2020 IHP includes the following argument: As to the issue of hypertension, it is the veteran's contentions that during his military service, it experienced multiple episodes of elevated blood pressure. The veteran since, has been diagnosed with hypertension. Service treatment records are consistent, by definition, with the veteran's claim of pre-hypertension during service. Next, with respect to the claim for service connection for cerebrovascular accident (stroke), the Veteran's theory of entitlement is one of secondary service connection. It is the veteran's belief that his high blood pressure was a contributing factor to the stroke he suffered in 2009. According to the Heart Association, most people who've had a first stroke also had high blood pressure (HBP or hypertension). Weakened arteries in the brain, resulting from high blood pressure, put you at a much higher risk for stroke. The IHP cites an Internet link from www.heart.org. The webpage shows, "Most people who've had a first stroke also had high blood pressure (HBP or hypertension)." "Most people" is not definite. It also does not show that this is peer-reviewed medical literature or based upon the Veteran's particular circumstances. The IHP also shows that the Veteran has had headaches continuously since 1997. The Board observes that the Veteran is already service-connected for migraine headaches. Additional VA treatment records are substantially the same, and show a history of two strokes from 2009. The Veteran's central theory of entitlement is that hypertension manifest in service, resulting in disability, and this caused a subsequent cardiovascular accident after separation. For these issues, in the February 2021 Brief, counsel highlights that the VA examiner must consider any blood pressure readings sufficient to identify the disease entity prior to its formal diagnosis. See February 2021 Brief, pp. 4-5. Counsel concedes that the VA examiner "noted BP readings" but argues that the examiner failed to comment on whether these besides the discharge examination were manifestations of the hypertension disease entity. This gives short shrift to the opinions and rationale offered by the VA examiner based upon the critical discharge examination. Appeals counsel requests a new VA examination to consider any elevated blood pressure readings throughout service that may represent characteristic manifestations of hypertension. Id. at p. 5. Counsel contends that the VA examiner's reliance on the lack of a formal diagnosis of hypertension in service constitutes an insufficient rationale. See February 2021 JMR, p. 5. Nevertheless, the quotation that precedes this shows that the VA examiner reproduced and considered numerous in-service blood pressure readings in rendering a nexus opinion. This stands in contrast to the representation by appeals counsel in the February 2021 Brief. The VA examiner's "comment" on the blood pressure readings was the examination's nexus opinion itself, grounded in the STRs. Based upon these specific requests in the JMR, the Board remanded the issue in July 2021 for a new VA examination with medical opinions. Turning to a cerebrovascular accident, the February 2021 JMR shows that this issue is inextricably intertwined with the hypertension issue and warrants a remand under Harris, 1 Vet. App. At 183. It reads, "Because a favorable decision on the claim for hypertension may impact Appellant's claim for entitlement to service connection for a cerebrovascular accident, the parties agree that remand of the latter claim is also warranted." See February 2021 JMR, p. 6. In this regard, the Board observes that the February 2021 Brief cites Jandreau and references that the Veteran competently reported that his doctor told him that high blood pressure was a contributing factor to his stroke. See February 2021 Brief, p. 7. Although competent to relate such an opinion under Jandreau, this does not necessarily mean that the conclusory nexus opinion is credible or probative. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The Board is mindful of the same requirements for an adequate examination as raised by appeals counsel with respect to the October 2019 VA examination. For example, as described by appeals counsel, a medical opinion could describe the nature of the relationship between the disease entities, e.g. causation or aggravation, with reasons and bases citing to evidence in the claims file. On remand, appeals counsel was invited to submit any private medical opinions from the Veteran's doctor or other evidence for consideration by the VA examiner prior to the Board's forthcoming decision. The Board ultimately Board remanded these issues in July 2021. Months later, the Veteran was afforded a set of November 2021 VA examinations with medical opinions. The medical nexus opinion for hypertension ends in part: If we are diagnosing hypertension according to these guidelines, the veteran appears to not have had any chronically consistent or elevated readings >140/90 during his time in service. Given that there were no consistently sustained readings of >140/90 in the STRs during active service or shortly after discharge from active service, it is less likely that the veteran's HTN started during active service. Hypertension is a significant risk factor for the occurrence of stroke. However, diabetes, CAD, hyperlipidemia and sleep apnea are also significant risk factors in causing stroke. Given the presence of these four other significant risk factors in combination with HTN, I am unable to state that the stroke is 50% greater approximately attributed to the HTN as all of these comorbidities have significant risk in contributing to stroke/cerebrovascular accidents. Earlier in section 4C., the VA examiner also provided a negative nexus opinion for secondary service connection for the claimed cerebrovascular accident (CVA). It reads: I opine that the claimed CVA is less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran's HTN. Hypertension is a significant risk factor for the occurrence of stroke. However, diabetes, CAD and sleep apnea are also significant risk factors in causing stroke. Given the presence of these three other significant risk factors in combination with HTN, I am unable to state that the stroke is 50% greater approximately attributed to the HTN as all of these comorbidities have significant risk in contributing to stroke/cerebrovascular accidents. Significantly, despite these lengthy medical opinions, the Veteran through his representative continues to challenge the adequacy of the VA examinations and the examiner's rationale. See February 2022 IHP. They suggest via quotations from caselaw that a remand is necessary to correct generally-alleged errors. The Veteran nor his representative specifies which aspects of the examinations they believe are in error, or what specific remedy is warranted. Still, they continue to assert, "VA erred when it failed to ensure to provide an adequate examination." Id. At this time, there are multiple negative nexus opinions, but their adequacy has been repeatedly challenged. The Veteran has obtained a February 2021 JMR and has since argued for further remands to obtain new VA examinations, citing statutes and caselaw. See February 2022 IHP. Therefore, in light of these allegations, a remand is warranted for another set of VA examinations to determine the nature and etiology of the claimed hypertension and cerebrovascular accident. In addition, the February 2022 IHP now presents a new theory of entitlement of secondary service connection to service-connected chronic obstructive pulmonary disease (COPD). The Veteran through his representative cites Mayo Clinic literature. The argument reads, "Mayo clinic reports COPD may cause high blood pressure in the arteries that bring blood to your lungs (pulmonary hypertension)." The Board did not previously order an examination for the cerebrovascular accident issue in the last remand because it was intertwined with the development for hypertension. To expedite the appeals, the Board will order a discrete examination with medical opinion for the claimed cerebrovascular accident issue. Both new examinations will now include the new secondary theory of entitlement with respect to service-connected COPD. Although remanding these issues for supplemental VA examinations, the Board declines to comment on the adequacy of the recent November 2021 VA examinations with medical opinions. Therefore, a remand for supplemental VA examinations with medical opinions is warranted. See 38 U.S.C. § 5103A (d); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The matters are REMANDED for the following action: 1. If the Veteran identifies other evidence, obtain updated copies of the Veteran's VA treatment records, and associate them with the Veteran's claims folder. 2. Please schedule the Veteran for a VA examination to determine the nature and etiology of any right foot disability. The claims file should be made available to the VA examiner. For each diagnosed disability, the VA examiner is requested to answer whether it is at least as likely as not that the disability was incurred in or is otherwise related to the Veteran's active military service. Pursuant to the February 2021 Joint Motion for Remand (JMR), any necessary diagnostic testing should be conducted to determine the presence of alleged glass in the right foot. If an x-ray will not suffice in the judgment of the examiner, this may also include a probe or other diagnostic technique, to the extent possible. Attention is invited to the November 2021 VA examination with medical opinion. The examiner should provide a rationale for all opinions expressed. 3. Please schedule the Veteran for a VA examination to determine the nature and etiology of any hypertension. The claims file should be made available to the VA examiner. For each diagnosed disability, the VA examiner is requested to answer whether it is at least as likely as not that the disability was incurred in or is otherwise related to the Veteran's active military service. The VA examiner should comment on blood pressure readings and any relevant symptoms manifested in service. See STRs; August 2018 Hearing Transcript, p. 14. Pursuant to the February 2021 JMR, the VA examiner should discuss whether any noted blood pressure readings in service represent characteristic manifestations of later-diagnosed hypertension, even if there was no formally documented diagnosis of the disease entity at separation. Attention is invited to the November 2021 VA examination with medical opinion. The VA examiner should also opine whether any diagnosed hypertension disability is proximately due to, the result of, or aggravated by the Veteran's service-connected chronic obstructive pulmonary disease (COPD). The examiner should provide a rationale for all opinions expressed. 4. Please schedule the Veteran for a VA examination to determine the nature and etiology of any cerebrovascular accident or stroke (VA). The claims file should be made available to the VA examiner. For each diagnosed disability, the VA examiner is requested to answer whether it is at least as likely as not that the disability was incurred in or is otherwise related to the Veteran's active military service. The VA examiner should also opine whether any diagnosed cerebrovascular accident (CVA) or stroke disability is proximately due to, the result of, or aggravated by the Veteran's claimed hypertension or service-connected chronic obstructive pulmonary disease (COPD). The examiner should provide a rationale for all opinions expressed. 5. Upon obtaining the completed clarification and development ordered above (to the extent possible), review the claims file to ensure that it addresses the three issues on appeal. Any inadequacies should be addressed prior to recertification to the Board. (Continued on the next page.) 6. After completing the above, and any other necessary development, the claims remaining on appeal must be readjudicated in light of all pertinent evidence and legal authority. If any benefits sought are not granted, issue the Veteran and his representative an appropriate supplemental statement of the case (SSOC). Michael A. Pappas Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Bodi, 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.