Citation Nr: 1746948 Decision Date: 10/20/17 Archive Date: 10/31/17 DOCKET NO. 14-00 016 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma THE ISSUE Entitlement to service connection for hypertension, to include as secondary to service-connected disease or injury. REPRESENTATION Appellant represented by: Oklahoma Department of Veterans Affairs WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Mary C. Suffoletta, Counsel INTRODUCTION The Veteran served on active duty from June 1968 to December 1971, including service in the Republic of Vietnam from April 1969 to April 1970. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a July 2013 rating decision that, in pertinent part, denied service connection for hypertension. The Veteran timely appealed. In January 2014, the Veteran effectively withdrew his appeal for service connection for neuropathy of each lower extremity. In November 2016, the Veteran testified during a video conference hearing before the undersigned. During the hearing, the undersigned granted the Veteran's request for a 60-day abeyance to submit additional evidence or argument directly to the Board. In January 2017, the Veteran requested additional time to submit evidence. In February 2017, the Veteran submitted additional evidence to the Board. The Board accepts that evidence for inclusion in the record. See 38 C.F.R. § 20.709 (2016). FINDING OF FACT Hypertension is attributable to service. CONCLUSION OF LAW Hypertension was incurred in active service. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2016). REASONS AND BASES FOR FINDING AND CONCLUSION I. Duties to Notify and Assist VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2016). These duties have been satisfied in this appeal. All available records identified by the Veteran as relating to his claim have been obtained, to the extent possible. Reports of VA examinations in connection with the claim on appeal are of record and appear adequate. The opinions expressed therein are predicated on a substantial review of the record and consideration of the Veteran's complaints and symptoms. The Veteran has not identified, and the record does not otherwise indicate, any existing pertinent evidence that has not been obtained. Given these facts, there is no further assistance that would be reasonably likely to assist the Veteran in substantiating the claim. 38 U.S.C.A. § 5103A(a)(2). II. Analysis Service connection is awarded for disability that is the result of a disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131. Service connection requires competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." 38 C.F.R. § 3.303(b). If a condition noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. Id. The Federal Circuit has held that section 3.303(b) applies only to those chronic conditions specifically listed in 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Notably, hypertension is considered chronic and a presumptive disease. See 38 U.S.C.A. § 1101. The Veteran seeks service connection for hypertension which he believes had its onset in active service, and is associated with his service-connected post-traumatic stress disorder (PTSD). Clinical evaluation at the time of the Veteran's enlistment examination in February 1968 reveals a blood pressure reading of 116/70. Records show that the Veteran was treated for chest pains in June 1971; his blood pressure reading at that time was 140/100, and the urinalysis report noted hypertension. A follow-up blood pressure check the next week revealed a reading of 133/88. Army Reserves records reveal a blood pressure reading of 118/88 in December 1976. On a "Report of Medical History" completed by the Veteran at that time, he checked "yes" in response to whether he ever had or now had high or low blood pressure. The examiner noted hypertension in service, controlled with weight loss. The report of a June 2013 VA examination reveals a diagnosis of hypertension. The examiner noted that the Veteran's medical history reveals that he was never prescribed any medication for hypertension in active service, and that he had no history of diastolic blood pressure elevation to predominantly 100 or more. Based on examination and review of the Veteran's medical history, the June 2013 examiner opined that the Veteran's hypertension was less likely than not (less than a 50 percent probability) incurred in or caused by the single episode of pain-induced blood pressure elevation during a visit for musculoskeletal chest pain in June 1971. The June 2013 examiner reasoned that pain, in and of itself, can cause transient elevation of blood pressure; and that the single episode of pain-induced blood pressure elevation was less likely than not the cause of sustained hypertension. In January 2014, a private physician noted the Veteran's medical history in active service as showing a blood pressure reading of 140/100 and diagnosis of hypertension in December 1971. In November 2016, the Veteran testified that he was first diagnosed with hypertension in active service, and was not prescribed medication at that time. Currently, he had four prescribed medications for hypertension. The Veteran also testified that there were multiple notations of elevated blood pressure in active service and Army Reserves service. Here, the Veteran is competent to report what occurred in service because his statements regard his first-hand knowledge of a factual matter. Accordingly, the Board finds the Veteran's lay statements as credible and probative. In a February 2017 addendum, the same private physician noted that symptoms of elevated blood pressure are related to the Veteran's diagnosed hypertension; and opined that it is as likely as not (50 percent or greater) that the Veteran's hypertension is directly related to and/or aggravated by his active service and by his ongoing condition of service-connected PTSD. The private physician referenced studies with indicate a higher prevalence of hypertension among persons suffering from PTSD. The private physician explained that the Veteran had a 50 percent disability rating for PTSD, and a history of above-normal blood pressure measurements dating to active service. When assessing the probative value of a medical opinion, the thoroughness and detail of the opinion must be considered. The opinion is considered probative if it is definitive and supported by detailed rationale. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). A medical opinion that contains only data and conclusions is not entitled to any weight. "It is the factually accurate, fully articulated, sound reasoning for the conclusion, not the mere fact that the claims file was reviewed, that contributes probative value to a medical opinion." See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Board notes that, in this case, there are conflicting medical opinions. The Board finds the private physician's addendum in February 2017, which related elevated blood pressure readings in active service to the Veteran's currently diagnosed hypertension; and acknowledged the prevalence of hypertension among persons suffering from PTSD, as persuasive. The private physician's opinion is fully articulated and contains sound reasoning, and is supported by the evidence of record. Notably, the Veteran had reported a history of elevated blood pressure readings both in active service and following active service. Moreover, the Board finds that there is credible evidence that the Veteran experienced symptoms of elevated blood pressure in active service. In Buchanan v. Nicholson, 451 F.3d 1331, 1337 (2006), the Federal Circuit Court indicated that, where lay evidence provided is competent and credible, the absence of contemporaneous medical documentation during service or since, such as in treatment records, does not preclude further evaluation as to the etiology of the claimed disorder. While sustained hypertension was not diagnosed until many years later, a plausible nexus to active service or to service-connected disease or injury cannot be excluded. Hence, the Board finds the February 2017 opinion is probative. In this case, the Board finds that the evidence is in favor of finding that hypertension is related to the in-service symptoms of elevated blood pressure. The Board acknowledges the June 2013 VA opinion, in which the examiner reasoned that a single episode of pain-induced blood pressure elevation was less likely than not the cause of sustained hypertension. The Board finds this opinion to be less persuasive than the Veteran's lay statements of ongoing symptomatology. In particular, the June 2013 examiner had recognized a diagnosis of hypertension in active service in 1971, but then relied on the lack of prescribed medications for hypertension in the years immediately following active service to find against the relationship. This is an inadequate reason for a negative finding. See Buchanan, 451 F.3d at 1337 (holding that the Board cannot determine that lay evidence as to diagnosis and nexus lacks credibility merely because it is unaccompanied by contemporaneous medical evidence); see also, Hensley v. Brown, 5 Vet. App. 155 (1993). In contrast to the VA opinion, there are the supporting opinions of the private physician noted above and the Veteran's contentions, which have been consistent throughout the appeal. Particularly, the Veteran testified that he was first diagnosed with hypertension in active service, and that hypertension was noted on his Army Reserves entrance physical. The Board finds that the Veteran is credible in this regard. The treatment records indicate a longstanding history of symptomatology. His statements are consistent with the circumstances of his service, and are not expressly contradicted by the record. When considering the service treatment records, the competent and credible lay statements, the post-service medical evidence substantiating the Veteran's claim, as well as the private physician's favorable opinion; and resolving all reasonable doubt in his favor, the Board finds that hypertension is related to in-service symptoms of elevated blood pressure. See 38 C.F.R. § 3.102. ORDER Service connection for hypertension is granted. ____________________________________________ H. N. SCHWARTZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs