Citation Nr: 1444875 Decision Date: 10/08/14 Archive Date: 10/16/14 DOCKET NO. 06-35 874 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to service connection for hypertension. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD N. T. Werner, Counsel INTRODUCTION The Veteran served on active duty from October 1978 to April 1985. This case comes before the Board of Veterans' Appeals (Board) on appeal from a March 2005 rating decision by the St. Petersburg, Florida Regional Office (RO) of the Department of Veterans Affairs (VA). In April 2009, the Board remanded the appeal for additional development. After the development was completed, the Board denied the appeal in a November 2009 decision. In December 2009, the Veteran requested reconsideration of the November 2009 Board decision, pursuant to 38 C.F.R. § 20.1000 and 20.1001. In September 2010, the Board vacated its November 2009 decision and remanded the claim for further development. In a May 2012 decision, the Board again denied service connection for hypertension. The Veteran appealed the May 2012 Board decision to the United States Court of Appeals for Veterans Claims (Court). In July 2013, the Veteran and the Secretary entered into a joint motion for remand (JMR) in which it was agreed to vacate and remand the Board decision to the extent that it denied service connection for hypertension. In October 2013 and in April 2014, the Board again remanded the appeal for additional development. FINDING OF FACT The preponderance of the evidence of record shows that the Veteran's hypertension is not related to service and hypertension did not manifest itself to a compensable degree within one year of service. CONCLUSION OF LAW Hypertension was not incurred in or aggravated by military service and it may not be presumed to have been incurred in service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1116, 1131, 5100, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Under 38 U.S.C.A. § 5102 VA first has a duty to provide an appropriate claim form, instructions for completing it, and notice of information necessary to complete the claim if it is incomplete. Second, under 38 U.S.C.A. § 5103(a), VA has a duty to notify the claimant of the information and evidence needed to substantiate and complete a claim, i.e., existence of a current disability, the degree of disability, and the effective date of any disability benefits. The appellant must also be notified of what specific evidence he is to provide and what evidence VA will attempt to obtain. Third, VA has a duty to assist claimants in obtaining evidence needed to substantiate a claim. This includes obtaining all relevant evidence adequately identified in the record and, in some cases, affording VA examinations. 38 U.S.C.A. § 5103A. In Dingess v. Nicholson, 19 Vet. App. 473, 490 (2006), the United States Court of Appeals for Veterans Claims (Court) observed that a claim of entitlement to service connection consists of five elements, of which notice must be provided prior to the initial adjudication: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date. See 38 U.S.C. § 5103(a). Initially, the Board finds that a letter dated in August 2004, prior to the March 2005 rating decision, and letters dated in November 2006 and October 2013 provided the Veteran with notice that fulfills the provisions of 38 U.S.C.A. § 5103(a) including notice of the laws and regulations governing disability ratings and effective dates as required by the Court in Dingess. While the Veteran may not have been provided adequate 38 U.S.C.A. § 5103(a) notice prior to the adjudication of the claim, the Board finds that providing him with adequate notice in the above letters followed by a readjudication of the claim in the August 2014 supplemental statement of the case "cures" any timing problem associated with inadequate notice or the lack of notice prior to the initial adjudication. Mayfield v. Nicholson, 20 Vet. App. 537 (2006) (Mayfield III), citing Mayfield II, 444 F.3d at 1333-34. The Board also finds that even if VA had an obligation to provide the Veteran with additional 38 U.S.C.A. § 5103(a) notice and failed to do so this notice problem does not constitute prejudicial error in this case because the record reflects that a reasonable person could be expected to understand what was needed to substantiate the claims after reading the above letters, the rating decision, the statement of the case, the supplemental statements of the case, and the Board remands. See Shinseki v. Sanders, 129 S.Ct. 1696 (2009). As to the duty to assist, the Board finds that VA has secured all available and identified pertinent in-service and post-service evidence including the Veteran's service treatment records and all available records from the Tampa and Bronx VA Medical Centers, including any inpatient records, charts, and/or logs from the Veteran's hospitalization at the Bronx VA Medical Center from September 5, 1985, to September 13, 1985, in substantial compliance with the Board's remand instructions as well as the July 2013 JMR. See 38 U.S.C.A. § 5103A(b); Stegall v. West, 11 Vet. App. 268 (1998); D'Aries v. Peake, 22 Vet. App. 97 (2008) (holding that only substantial, and not strict compliance with the terms of a remand request, is required); Dyment v. West, 13 Vet. App. 141, 146-47 (holding that there was no Stegall violation when the examiner made the ultimate determination required by the Board's remand, because such determination more than substantially complied with the Board's remand order). In this regard, the record shows that after requesting the Veteran's August 1985 treatment records from the Brooklyn Hospital Center in December 2013 and January 2014, Brooklyn Hospital Center notified VA in February 2014 that it did not have any of his treatment records. In April 2014, VA notified the Veteran of this fact. Therefore, the Board finds that adjudication of this claim may go forward without these records. See Gobber v. Derwinski, 2 Vet. App. 470, 472 (1992) (the "'duty to assist' is not a license for a 'fishing expedition' to determine if there might be some unspecified information which could possibly support a claim . . . [and] this duty is limited to specifically identified documents that by their description would be facially relevant and material to the claim"). The record also shows that VA obtained opinions as to the origins of the Veteran's hypertension in June 2009, September 2010, and December 2013. Moreover, the Board finds the post-JMR VA examination adequate to adjudicate the claim and substantially complied with the Board's remand instructions and the JMR because after a review of the record on appeal, after taking a detailed medical history from the claimant, and after an examination, the examiner provided an opinion as to the origins of his hypertension which opinion was based on citation to relevant evidence found in the claims file as well as a discussion of Dr. Craig N. Bash's reports. See 38 U.S.C.A. § 5103A(d); Barr v. Nicholson, 21 Vet App 303 (2007); Stegall, supra; D'Aries, supra; Dyment, supra. In summary, the facts relevant to this appeal have been properly developed and there is no further action to be undertaken to comply with the provisions of 38 U.S.C.A. §§ 5103(a), 5103A or 38 C.F.R. § 3.159. Therefore, the Veteran will not be prejudiced as a result of the Board proceeding to the merits of the appeal. See Bernard v. Brown, 4 Vet. App. 384, 392-94 (1993). In adjudicating the claims below, the Board has reviewed all of the evidence in the VBMS claims file as well as in virtual VA. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that all the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the Veteran's claim folder shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). The Claim The Veteran contends that service connection for hypertension is warranted because the disease is either related to or had its onset in service. Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303. If a condition noted during service is not shown to be chronic, then generally a showing of continuity of symptomatology after service is required for service connection if the disability is one that is listed in 38 C.F.R. § 3.309(a) which disabilities includes hypertension. 38 C.F.R. § 3.303(b); see also Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In addition, service connection may also be granted on the basis of a post-service initial diagnosis of a disease, where the physician relates the current condition to the period of service. 38 C.F.R. § 3.303(d). Other specifically enumerated disorders, including hypertension will be presumed to have been incurred in service if they manifested to a compensable degree within the first year following separation from active duty. 38 U.S.C.A. §§ 1101, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2013). In order to establish service connection for the claimed disability, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). The requirement of a current disability is "satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim." See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). In evaluating the evidence in any given appeal, it is the responsibility of the Board to weigh the evidence and decide where to give credit and where to withhold the same and, in so doing, accept certain medical opinions over others. Schoolman v. West, 12 Vet. App. 307, 310-11 (1999). In this regard, the Board has been charged with the duty to assess the credibility and weight given to evidence. Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). Indeed, the Court has declared that in adjudicating a claim, the Board has the responsibility to do so. Bryan v. West, 13 Vet. App. 482, 488-89 (2000). In doing so, the Board is free to favor one medical opinion over another, provided it offers an adequate basis for doing so. Evans v. West, 12 Vet. App. 22, 30 (1998). As to a current disability, the post-service record shows the Veteran being diagnosed with hypertension. See, for example, VA examination dated in June 2009. As to service incurrence under 38 C.F.R. § 3.303(a), service treatment records show the Veteran had elevated blood pressure readings of 140/90 and 142/98, in May and December 1984. Moreover, during the course of his appeal the Veteran stated that he was told by medical staff in service that his blood pressure readings were high and was asked on multiple occasions if he had high blood pressure to which he responded no because he had not been diagnosed at that time. However, the May and December 1984 blood pressure readings were taken at a time when the Veteran was being treated for a trauma-a puncture wound. Additionally, the May and December 1984 elevated blood pressure readings, standing alone, cannot provide such a diagnosis of hypertension because VA requires that blood pressure readings must be taken two or more times on at least three different days to support a diagnosis of hypertension. See 38 C F R § 4 104, Diagnostic Code 7101 (Note 1) (2013). Moreover, the service treatment records, including those from May and December 1984, are negative for complaints or a diagnosis of hypertension. In fact, the Board notes that in December 1983 and March 1984 service records the Veteran reported, in essence, that he never had or was treated for hypertension. Further, while the Veteran as a lay person is competent to report on his symptoms of hypertension because this requires only personal knowledge as it comes to him through his senses, the Board finds that he is not competent to provide a diagnosis of hypertension because such an opinion requires medical expertise which he does not have. See Davidson. Therefore, the Board finds more compelling the service treatment records, including the May and December 1984 treatment records, which is negative for a diagnosis of hypertension than any claim by the appellant that he had problems with hypertension while on active duty. See Kahana v. Shinseki, 24 Vet. App. 428, 440 (2011) ("[T]he Board may use silence in the [service medical records] as contradictory evidence only if the alleged injury, disease, or related symptoms would ordinarily have been recorded in the [service medical records]." citing to Fed .R. Evid. 803(7) (the absence of an entry in a record may be evidence against the existence of a fact if such a fact would ordinarily be recorded).). Accordingly, the Board finds that the most probative evidence of record shows that the Veteran did not have hypertension while on active duty. Accordingly, the Board finds that entitlement to service connection for hypertension must be denied based on in-service incurrence despite the two elevated blood pressure readings seen while on active duty and despite the Veteran's claims regarding having problems with observable symptoms of this disability while on active duty. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303(a). As to the presumptions found at 38 C.F.R. § 3.309(a), the Board notes that the record does not show the Veteran being diagnosed with hypertension in the first post-service year. Accordingly, the Board finds that entitlement to service connection for hypertension must be denied on a presumptive basis. See 38 U.S.C.A. §§ 1110, 1112, 1113, 1131; 38 C.F.R. §§ 3.303, 3.307, 3.309. As to post-service continuity of symptomatology under 38 C.F.R. § 3.303(b), the Board finds that the length of time between the Veteran's separation from active duty in 1985 and the first diagnosis of hypertension in the late 1990's to be evidence against finding continuity. See, for example, Dr. Edward Braun's treatment records dated from March 1999 to December 2004. In this regard, the Board notes that while the record documents the fact that the Veteran had, on occasion, elevated blood pressure readings prior to this time including when being treated for a stab wound to the arm at VA in August 1985, the record during this time was nonetheless negative for a diagnosis of hypertension. Similarly, the Board acknowledges, as it did above, that the Veteran is competent to give evidence about what he sees and feels; for example, the claimant is competent to report that he had problems with observable symptoms of hypertension, such as dizziness, since service. See Davidson. However, upon review of the claims file, the Board finds that the lay accounts from the Veteran and others that the appellant has had his hypertension since service are not credible. In this regard, these lay claims are contrary to what is found in the service and post-service records including the service treatment records that document elevated blood pressure but did not thereafter diagnose hypertension, the service treatment records in which the Veteran denied having high blood pressure, and the other service treatment records that did not diagnose him with hypertension. Post-service, the Board finds the fact that in a November 1993 VA treatment record the Veteran specifically denied a history of hypertension and the fact that the post-service records prior to the mid-1990's do not note a history of hypertension or provide a diagnosis also weighs heavily against the claims of continuity. In these circumstances, the Board gives more credence and weight to the negative service treatment records as well as the negative post-service treatment records, than any claims by the Veteran and his representative to the contrary. Therefore, entitlement to service connection for hypertension based on post-service continuity of symptomatology must be denied. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303(b). As for service connection based on the initial documentation of the disability after service under 38 C.F.R. § 3.303(d), in an October 2009 opinion Dr. Bash indicated that the Veteran had many elevated blood pressure readings in service at the 142/98 level and 140/90 in 1984. He opined that the Veteran had hypertension (diastolic and systolic) in service and stated that this finding was apparent from the above record. He further indicated that the hypertension is related to service, as the Veteran's records do not support another etiology. Thereafter, in November 2011 Dr. Bash submitted a nearly identical opinion to the one he provided in October 2009. Subsequently, in December 2013 Dr. Bash submitted another opinion. In this regard, after a review of the record on appeal and an examination of the Veteran, Dr. Bash opined that it is as likely as not that the Veteran had hypertension while in the service based on the "Joint National Committee 7" definition for hypertension. He thereafter opined that the Veteran's current high blood pressure is due to his service time hypertension as his records do not support another etiology. In support of this conclusion, Dr. Bash cites to the Veteran's blood pressure readings while on active duty in 1984 that were at 142/98 and 140/90 levels and his blood pressure readings post-service in 1985 at the Bronx VA Medical Center which were at the 142/96 level for a period of five days. On the other hand at the June 2009 VA examination, after examining the Veteran and reviewing the claims file, the examiner opined that the current hypertension disorder was not related to service. The rationale was that there was no treatment for essential hypertension, or any such diagnosis, in service or within a year of discharge. The examiner explained that the only noted elevated blood pressure reading was on May 12, 1984, and this occurred with an acute puncture wound. The examiner explained that the acute injury caused that elevated blood pressure reading. The private medical records from 1985 to 1993 did not document any diagnosis of hypertension, and another elevated blood pressure reading in 1985 was with an acute stab wound only. That injury was also acute in nature and resulted in elevated blood pressure, but not a diagnosis of hypertension. The Veteran was not treated for hypertension until 1994, many years after discharge from service. Similarly in the September 2010 addendum, after reviewing Dr. Bash's opinions the VA examiner reaffirmed her conclusion that the Veteran's hypertension was not caused by or related to his military service. The examiner's clinical rationale was identical to that provided in June 2009. Likewise, at the December 2013 VA examination after a review of the record on appeal including Dr. Bash's opinions and examination of the Veteran, it was opined that it is not at least as likely as not that any hypertension or hypertensive vascular disease is etiologically related to or had its onset in service to include his May 1984 elevated blood pressure readings and it is not at least as likely as not that any hypertension or hypertensive vascular disease became manifest within one year of his discharge from active duty. In support of its conclusion that the Veteran's hypertension/hypertensive vascular disease was not related to service, the examiner reasoned as follows: REVIEW OF THIS VETERAN SERVICE MEDICAL RECORDS WAS ACCOMPLISHED. ALL OF THE BLOOD PRESSURE READINGS RECORDED WHILE THIS VETERAN WAS ON ACTIVE DUTY FROM 1978 UNTIL 1985 WERE REVIEWED. ALL OF THE SYSTOLIC AND ALL OF THE DIASTOLIC READINGS DOCUMENTED ON ACTIVE DUTY WERE < 140 SYSTOLIC AND < 90 DIASTOLIC EXCEPT FOR 2 READINGS BP READINGS: MAY 12, 1984 = 142/98 AND DECEMBER 5, 1984= 140/90. ACCORDING TO JOINT NATIONAL COMMISSION 7, THE DEFINITION OF HYPERTENSION IS A PATTERN OF BLOOD PRESSURE READINGS >140 SYSTOLIC AND/OR >90 DIASTOLIC. BUT THE UP-TO-DATE DEFINITION INCLUDES SEVERAL IMPORTANT POINTS: 1. 'A PATIENT SHOULD NOT BE LABELED AS HAVING HYPERTENSION UNLESS THE B.P. IS PERSISTENTLY ELEVATED AFTER 3-6 VISITS OVER A SEVERAL MOS. PERIOD.' 2. ACCORDING TO 'UP-TO-DATE" MEDICAL SOURCE REGARDING THE ACCEPTABLE WAY TO MEASURE B.P. IN A SUSPECT FOR DIAGNOSIS OF HYPERTENSION IS AS FOLLOWS' 'THESE DEFINITIONS APPLY TO ADULTS ON NO ANTIHYPERTENSIVE MEDICATIONS AND WHO ARE NOT ACUTELY ILL.' THIS VETERAN WAS SEEN IN THE EMERGENCY ROOM FOR BOTH OF THE ELEVATED B.P. READINGS. THE READING OF MAY 12, 1884 WAS FOR A 'PUNCTURED LEFT HAND,' AND THE READING OF 12-5-1984 WAS FOR A 'PUNCTURE WOUND LEFT PALM.' THUS, BOTH THESE BLOOD PRESSURE READINGS WOULD NOT QUALIFY IN ANY FORMAL DIAGNOSIS OF HYPERTENSION, SINCE A NORMAL PERSON MAY HAVE ELEVATION IN BLOOD PRESSURE DURING AN ACUTE INJURY OR ILLNESS. ALL THE OTHER ACTIVE DUTY B.P. READINGS WERE NOT >140/90. THIS PERSON WAS EVENTUALLY DIAGNOSED WITH ESSENTIAL HYPERTENSION ABOUT 1990. IN A LETTER OF CLAIM DENIAL DATED APRIL 8, 2005, A DOCUMENT THAT THIS VETERAN SIGNED CALLED 'HEALTH CARE PROVIDER CERTIFICATION' DOCUMENTS THAT THIS VETERAN STATED HIS HYPERTENSION COMMENCED IN 1990. RECORDS FROM HIS PRIMARY CARE DOCTOR, DR. EDWARD BRAUN, IN A PATIENT SUMMARY REPORT DATED 12-21-2004, NOTES THAT HE DIAGNOSED "ESSENTIAL HYPERTENSION, AFTER DOING SUCH TESTS AS A CAPTOPRIL RENAL SCAN AND 24 HOUR URINE METANEPHRINES TO RULE OUT OTHER CAUSES. ACCORDING TO THE MEDICAL SOURCE 'UP-TO-DATE, MOST PEOPLE WITH THE DIAGNOSIS OF HYPERTENSION HAVE "ESSENTIAL HYPERTENSION:' 'Most patients with hypertension have primary (essential) hypertension. The pathogenesis of primary hypertension is poorly understood. Numerous risk factors for developing hypertension have been identified, including black race, a history of hypertension in one or both parents, a high sodium intake, excess alcohol intake, excess weight....' THUS, ACCORDING TO UP-TO-DATE, WHAT IS THE ETIOLOGY OF THIS VETERAN'S HYPERTENSION? 'The pathogenesis of primary hypertension is poorly understood. Numerous risk factors for developing hypertension have been identified, including black race, a history of hypertension in one or both parents, a high sodium intake, excess alcohol intake, excess weight....' THIS VETERAN DID HAVE THE FOLLOWING RISK FACTORS FOR ESSENTIAL HYPERTENSION: 1. BLACK RACE[;] 2. FAMILY HISTORY OF HYPERTENSION WITH HIS FATHER (SEE VETERAN'S CLAIM FILE WITH CONSULTATION NOTE FROM DR. ANGEL ROSARIO AT UNIVERSITY COMMUNITY HOSPITAL DATED 6-11-01: 'FAMILY HISTORY SIGNIFICANT FOR HIS FATHER HAVING HYPERTENSION[;]' [and] 3. WEIGHT ELEVATION. THUS, FOR ALL THESE REASONS LISTED ABOVE, IT IS <50% LIKELY THAT THIS VETERAN'S HYPERTENSION OR HYPERTENSION VASCULAR DISEASE WAS INCURRED IN OR THE RESULT OF ACTIVE DUTY MILITARY SERVICE, INCLUDING THE 1984 B.P. READINGS. In support of its conclusion that the Veteran's hypertension/hypertensive vascular disease did not became manifest within one year of his discharge from active duty, the examiner reasoned as follows: ACCORDING TO THIS VETERAN ORIGINAL CLAIM FILED 8-17-2004, VETERAN STATES THAT THE HYPERTENSION BEGAN ON 1-1-1981 AND HE ALSO STATES HE WAS TREATED FROM 1-1-1981 UNTIL 8-1-2004 (MONTH OF CLAIM). THIS DOES NOT APPEAR ACCURATE, SINCE THE MILITARY RECORD CONTAINS THE FOLLOWING MEDICAL STATEMENTS: 1. A MILITARY RECORD DOCUMENT DATED 6 DECEMBER 1983 SHOWS THAT THE VETERAN CIRCLED THAT HE NEVER HAD OR WAS TREATED FOR HYPERTENSION [and]. 2. AN ADDITIONAL DOCUMENT IN THE MEDICAL MILITARY RECORD DATE 26 OCTOBER 1984 SHOWS THE VETERAN ANSWERED 'NO' TO THE FOLLOWING QUESTION: 'HIGH BLOOD PRESSURE?' ACCORDING TO A LETTER OF CLAIMS DENIAL DATED 4-8-05, A DOCUMENT THAT THIS VETERAN SUBMITTED ENTITLED 'HEALTH CARE PROVIDER CERTIFICATION' CERTIFIES THAT THE VETERAN STATED HIS HYPERTENSION COMMENCED IN 1990. THIS VETERAN LEFT ACTIVE DUTY IN JUNE, 1985, AND HE WAIVED HIS SEPARATION EXAMINATION AT THAT TIME. THERE ARE NO BLOOD PRESSURE READINGS THAT ARE DOCUMENTED IN THE CLAIMS FILES FOR THE 1 YEAR PERIOD AFTER LEAVING ACTIVE DUTY (JUNE, 1985 - JUNE, 1986). THUS, THERE IS NO EVIDENCE TO SUPPORT A CLAIM THAT THE HYPERTENSION BECAME MANIFEST WITHIN 1 YEAR OF LEAVING ACTIVE DUTY. THUS, IT IS <50% LIKELY THAT THIS VETERAN'S HYPERTENSION OR HYPERTENSIVE VASCULAR DISEASE BECAME MANIFEST WITHIN 1 YEAR OF LEAVING ACTIVE DUTY IN JUNE, 1985. As to Dr. Bash's findings, conclusions, and rationale, the December 2013 VA examiner opined as follows: DR. BASH DOES NOT LIST THE MOST ACCEPTED SOURCE FOR HYPERTENSION ISSUES: THE JOINT NATIONAL COMMISSION -7. DR. BASH IS ALSO PRIMARILY PRACTICING IN RADIOLOGY, NOT A PRIMARY CARE SPECIALTY, WHICH DEALS WITH DIAGNOSIS OF HYPERTENSION ON A REGULAR BASIS. HE IS THUS NOT THE BEST EXPERT TO PROVIDE AN OPINION ON THIS DIAGNOSIS. IN RESPONSE TO DR. BASH'S OPINION, HE DID NOT QUOTE THE CORRECT CIRCUMSTANCES FOR THE DIAGNOSIS OF HYPERTENSION: 1. FROM UP-TO-DATE: 'A PATIENT SHOULD NOT BE LABELED AS HAVING HYPERTENSION UNLESS THE B.P. IS PERSISTENTLY ELEVATED AFTER 3-6 VISITS OVER A SEVERAL MOS. PERIOD.' 2. ACCORDING TO 'UP-TO-DATE' MEDICAL SOURCE REGARDING THE ACCEPTABLE WAY TO MEASURE B.P. IN A SUSPECT FOR DIAGNOSIS OF HYPERTENSION IS AS FOLLOWS 'THESE DEFINITIONS APPLY TO ADULTS ON NO ANTIHYPERTENSIVE MEDICATIONS AND WHO ARE NOT ACUTELY ILL.' THIS VETERAN WAS SEEN IN THE EMERGENCY ROOM FOR BOTH OF THE ELEVATED B.P. READINGS. THE READING OF MAY 12, 1[9]84 WAS FOR A "PUNCTURED LEFT HAND," AND THE READING OF 12-5-1984 WAS FOR A "PUNCTURE WOUND LEFT PALM." THUS, BOTH THESE BLOOD PRESSURE READINGS WOULD NOT QUALIFY IN ANY FORMAL DIAGNOSIS OF HYPERTENSION, SINCE A NORMAL PERSON MAY HAVE ELEVATION IN BLOOD PRESSURE DURING AN ACUTE INJURY OR ILLNESS. ALL THE OTHER ACTIVE DUTY B.P. READINGS WERE NOT >140/90. ADDITIONALLY, THIS VETERAN'S MEDICAL RECORDS FROM PRIVATE PHYSICIAN DR. EDWARD BRAUN DATE 12-21-2004 SHOW HE DID EXTENSIVE TESTING FOR A RENAL ETIOLOGY (CAPTOPRIL RENAL SCAN) AND OTHERS (24 HOUR URINE METANEPHRINES). THUS, AT THAT TIME, THERE WAS NO EVIDENCE THAT RENAL DISEASE WAS CAUSING THE HYPERTENSION. DR. BRAUN'S RECORDS LIST HIS DIAGNOSIS AS "ESSENTIAL HYPERTENSION" WHICH IS THE MOST COMMON DIAGNOSIS FOR HYPERTENSION. DR. BASH FAILS TO NOTE THE RISK FACTORS THAT THIS VETERAN HAD FOR ESSENTIAL HYPERTENSION, WHICH IS THE MOST COMMON CAUSE OF THIS DISEASE: 1. BLACK RACE[,] 2. FAMILY HISTORY[, and] 3. WEIGHT ELEVATION. THUS, DR. BASH'S STATEMENT AS FOLLOWS CANNOT BE SUPPORTED BY FACTUAL DATA: 'It is my opinion that this patient had HTN while in service and I officially give him that diagnosis now as it is apparent from the above record that this patient had hypertension (diastolic and systolic) while in the service....' THE ABOVE OPINION IS WRONG, SINCE BLOOD PRESSURE READING WERE CONSIDERED FOR DIAGNOSIS, WHICH SHOULD, IN FACT, NEVER HAD BEEN CONSIDERED FOR THE DIAGNOSIS. The Board finds that although the cumulative VA and private medical treatment records reflect long-standing treatment for hypertension, these records fail to demonstrate an etiological relationship between the currently manifested hypertension and service. The only evidence specifically pertaining to the question of causal nexus are the competing opinions provided by the VA examiner and Dr. Bash. The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. After careful consideration, the Board finds the VA examiners opinions that the Veteran's current hypertension is not etiologically related to military service to be both competent and the most persuasive on the question of nexus as they reflect a comprehensive analysis of the pertinent evidence and are otherwise supported by the evidence of record as well as citation to controlling medical authority. See Owens v. Brown, 7 Vet. App. 429, 433 (1995) (holding that VA may favor the opinion of one competent medical expert over that of another when decision makers give an adequate statement of reasons and bases). Dr. Bash's opinions are found to be less persuasive as they fail to address the fact that the only elevated blood pressure readings in service and within one year of discharge were noted only in connection with incidents of acute trauma. See Black v. Brown, 5 Vet. App. 177, 180 (1995) (holding that a medical opinion is inadequate when it is unsupported by clinical evidence); Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (a medical opinion based on an inaccurate factual premise is not probative). The Board also finds Dr. Bash's opinions to be less persuasive because, as pointed out by the December 2013 VA examiner, none of the opinions took into account the Veteran's three risk factors for hypertension. The Board also finds Dr. Bash's opinions less persuasive because notwithstanding Dr. Bash's claims to the contrary that the Veteran's record does not support another etiology for his hypertension but his active duty service, the record shows three other possible etiology (i.e., his race, his family history, and his elevated weight). Id. Further the Board finds that Dr. Bash's first two opinions internally inconsistent. In this regard, Dr. Bash pointed to two elevated blood pressure readings taken on the same day in May 1984 to show that hypertension existed in service; however, he also noted that a person is not diagnosed with hypertension unless their blood pressure is persistently high at two office visits at least one week apart, because many people are anxious when seeing a doctor or nurse. Thus, by Dr. Bash's own explanation, the Veteran's two isolated elevated blood pressure readings noted in May 1984 would not in fact support a diagnosis of hypertension. See Madden v. Gober, 125 F.3d. 1477 1481 (Fed. Cir. 1997) (holing that the Board is entitled to discount the credibility of evidence in light of its own inherent characteristics and its relationship to other items of evidence). The Board also finds Dr. Bash's first two opinions to be less persuasive because, as pointed out by the December 2013 VA examiner, they relied on the wrong medical standard. See Reonal. As to the lay claims from the Veteran and others that the appellant hypertension was caused by his military service, the Board finds the above VA examiners opinions more credible than these lay claims because healthcare professionals have more expertise. See Black v. Brown, 10 Vet. App. 297, 284 (1997) (in evaluating the probative value of medical statements, the Board looks at factors such as the individual knowledge and skill in analyzing the medical data). Moreover, the Board finds that diagnosing hypertension requires special medical training that these lay persons do not have and therefore the presence of the disorder is a determination "medical in nature" and not capable of lay observation. See Davidson. Accordingly, since laypersons are not capable of opining on matters requiring medical knowledge, the Board finds that their opinions that this disorder was caused by service is not competent evidence. Jandreau. Therefore, the Board finds that the most probative evidence of record shows that the Veteran's current hypertension was not caused by his military service. Accordingly, the Board finds that entitlement to service connection for hypertension is not warranted based on the initial documentation of the disability after service because the weight of the probative evidence is against finding a causal association or link between the post-service disorder and an established injury, disease, or event of service origin. See 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303(d). Accordingly, the Board must conclude that entitlement to service connection for hypertension must be denied because the weight of the evidence is against the claim. See 38 U.S.C.A. § 1131; 38 C.F.R. §§ 3.303, 3.310. ORDER Service connection for hypertension is denied. ____________________________________________ STEVEN D. REISS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs