Citation Nr: 1752901	
Decision Date: 11/17/17    Archive Date: 11/22/17

DOCKET NO. 13-03 745A	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Regional Office in Jackson, Mississippi


THE ISSUES

1. Entitlement to service connection for hypertension.

2. Entitlement to service connection for a heart disability, to include atrioventricular (AV) block with abnormal electrocardiogram (EKG), to include as secondary to hypertension.

3. Entitlement to service connection for tinea versicolor.

4. Entitlement to service connection for condyloma.

5. Entitlement to an initial disability rating in excess of 10 percent for lumbar spine strain with degenerative changes. 


REPRESENTATION

Veteran represented by:	Disabled American Veterans

WITNESS AT HEARING ON APPEAL

The Veteran


ATTORNEY FOR THE BOARD

D. Cheng, Associate Counsel


INTRODUCTION

The Veteran served on active duty from January 1991 to September 1996.

This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2012 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia.

In July 2017, the Veteran provided testimony in a video conference hearing before the undersigned Veterans Law Judge who noted the issue on appeal and engaged in a colloquy with the Veteran toward substantiation of the claim. See Bryant v. Shinseki, 23 Vet. App. 488, 496-97 (2010). A copy of the hearing transcript is associated with the claims file.

The issues of entitlement to service connection for a heart disability, to include AV block with abnormal EKG, to include as secondary to hypertension; entitlement to service connection for tinea versicolor; entitlement to service connection for condyloma; and entitlement to an initial disability rating in excess of 10 percent for lumbar spine strain with degenerative changes, are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ).



FINDING OF FACT

The Veteran's current hypertension was incurred in service.


CONCLUSION OF LAW

The criteria for service connection for hypertension have been met. 38 U.S.C. §§ 1101, 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 4.104, Diagnostic Code (DC) 7101 (2017).


REASONS AND BASES FOR FINDING AND CONCLUSION

Neither the Veteran nor the representative has raised any issues with the duty to notify or duty to assist. See Scott v McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (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 veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to duty to assist argument).

Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires (1) evidence of a current disability; (2) evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004).

In addition, service connection may also be established under 38 C.F.R. § 3.303(b) if a chronic disease or injury is shown in service, and subsequent manifestations of the same chronic disease or injury at any later date, however remote, are shown, unless clearly attributable to intercurrent causes. Cardiovascular-renal disease, including hypertension, are chronic conditions listed under 38 C.F.R. § 3.309(a); and thus, 38 C.F.R. § 3.303(b) is applicable. See38 U.S.C. § 1101; see also Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be established based upon a legal presumption by showing that a disorder manifested itself to a degree of 10 percent disabling or more within one year from the date of separation from service. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.307, 3.309(a).

When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 

Note (1) to 38 C.F.R. § 4.104, DC 7101 states hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three, different days. For the purposes of 38 C.F.R. § 4.104, the term hypertension means that the diastolic blood pressure is predominately 90mm. or greater and isolated systolic hypertension means that the systolic blood pressure is predominately 160mm. or greater with a diastolic blood pressure of less than 90mm. 

The Veteran contends that service connection for hypertension is warranted because it was incurred in service. 

The Veteran has a current diagnosis of hypertension, as indicated in an August 2016 VA medical record. The record also reflects that the Veteran's treatment for hypertension includes medications of amlodipine besylate and losartan. A September 2011 examination report shows that the Veteran was diagnosed with hypertension in 1996 and that he was treated with amlodipine and losartan. Furthermore, a service treatment record from August 1994 reveals a diagnosis of hypertension with blood pressures of 150's (systolic) /90's (diastolic). The Veteran's manifestation of symptoms and a diagnosis of hypertension in service and continuing since service separation tend to show that his current hypertension was incurred coincident with active service. See 38 C.F.R. §§ 3.303(a), 3.309
For these reasons, and resolving reasonable doubt in favor of the Veteran, the Board finds that the criteria for service connection for hypertension have been met. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102, Gilbert, 1 Vet. App. at 49.


ORDER

Entitlement to service connection for hypertension is granted.


REMAND

A review of the record discloses further development is needed with respect to the Veteran's claims of entitlement to service connection for a heart disability to include AV block with abnormal EKG, to include as secondary to hypertension; entitlement to service connection for tinea versicolor; entitlement to service connection for condyloma; and entitlement to an increased initial disability rating for his service-connected lumbar spine disability.

Heart disability

The Veteran contends that he has a heart disability, to include an AV block with abnormal EKG, which was incurred in service or otherwise related to service to include as secondary to hypertension. An August 1994 service treatment record reflects an abnormal EKG with atrioventricular block Mobitz type II, however the physician noted that it was asymptomatic. A VA examination provided in September 2011 indicates that the Veteran did not experience angina, shortness of breath, fatigue, dizziness or syncope attacks. The Veteran reported no congestive heart failure and had no history of rheumatic heart disease. The Veteran was not treated for the condition. A physical examination revealed normal size of the heart determined by palpation and normal S1 and S2. There was no evidence of S3 or S4 and the Veteran had a normal heart rate and regular rhythm. There was also no evidence of murmurs or gallops or heaves or thrills. The examiner made a specific finding that an examination of the heart did not reveal any evidence of congestive heart failure, cardiomegaly, or cor pulmonale (pulmonary heart disease). A May 2013 VA medical record shows that the Veteran reported having a fast heart rate. An EKG showed sinus tachycardia with evidence of q waves in V1 and V2. The record also reflects a history of thoracic aortic aneurysm (root). In a November 2014 letter, a private medical doctor indicated that the Veteran had an enlarged heart with concentric left ventricular hypertrophy, per the echo report from Dr. K. The medical doctor opined that the Veteran's hypertrophied heart is likely a result of his long standing hypertension and is a likely contributor to his AV block. In a May 2014 VA medical record, the physician noted that there was no evidence of pulmonary aortic aneurysm and that there was a mild dilation of the distal aorta. An August 2016 VA medical record indicates that the Veteran had an echo which showed moderate aortic root dilation and that he had been seen in the emergency department in the past for chest pain which had a full negative cardiac workup (troponins, stress test, MPS, and EKG). 

As the Veteran will now be in receipt of service connection for hypertension and has a proffered a nexus opinion relating a heart disability and hypertension, the Board finds that a VA examination is necessary to determine if the Veteran has a current heart disability. 

Tinea Versicolor

The Veteran asserts that he has a skin disorder, specifically tinea versicolor that was incurred in service. A review of his service treatment record indicates that he was treated for tinea versicolor in service including in October 1991, July 1992, and April 1994. The September 2011 VA examination report reflects that the Veteran had no signs of skin disease. During the July 2017 Board video conference hearing, the Veteran testified that the VA examiner did not fully examine him in his determination that tinea was not present. The Veteran indicated that the examiner did not ask the Veteran to remove his shirt. The Veteran proffered a November 2014 letter from his independent medical expert who stated that the Veteran had tinea versicolor in service and had it on examination. He added that the Veteran should be service connected for tinea versicolor as the Veteran's records do not contain another more likely cause. In a January 2014 VA medical record, the physician noted that a skin examination showed extensive tinea versicolor. A November 2015 VA medical record reflects that the Veteran's skin showed no pruritus, rash, or new lesions. As the Veteran asserted that his skin disorder was not fully examined by the VA examiner and testified in the July 2017 video conference hearing that he would be willing to appear for another VA examination, the Board finds that the Veteran should be afforded a new examination to determine whether he currently has a skin disorder and the severity, if applicable.

Condyloma

The Veteran asserts that he has condyloma, also known as genital warts, that was incurred in service. April 1994, July 1994, and February 1995 service treatment records show that the Veteran sought treatment for recurrent condyloma. An October 1998 private medical record reflects treatment and a diagnosis of condyloma. The Veteran was afforded a VA examination in September 2011. The examiner indicated that the examination of the penis was normal with no evidence of deformity, masses, or tenderness. Further, he stated that there was no diagnosis of genital warts because there was no pathology to render a diagnosis. He added that the Veteran had condylomata during active service which was resolved or asymptomatic thus no relationship could be established during the examination. In an October 2011 addendum opinion, the examiner added that condyloma is a result or caused during active service. A May 2013 VA medical record reflects that the Veteran reported a history of genital warts. The Veteran testified at the July 2017 video conference hearing that he still had genital warts, at least a couple of them. He asserted that the examiner did not look and explained that his genital warts "comes and goes." The evidence of record indicates that the Veteran's condyloma was incurred in service and the Board finds that the Veteran should be afforded a new examination to determine whether he currently has condyloma.

Lumbar Spine

The Veteran contends that his lumbar spine disability is worse than the disability rating currently assigned. The Veteran was last afforded a VA examination in March 2017 in order to establish the severity of his lumbar spine disability. During the July 2017 Board hearing, the Veteran testified his lumbar spine disability increased in severity since his last VA examination. Therefore, the Board must remand this matter to afford the Veteran an opportunity to undergo a VA examination to assess the current nature, extent and severity of his lumbar spine disability. See Snuffer v. Gober, 10 Vet. App. 400, 403 (1997).

Accordingly, the case is REMANDED for the following actions:

1. Schedule the Veteran for a VA examination for his claimed heart disability, to include AV block with abnormal EKG, to determine the nature, extent, and etiology of the claimed disability. Any indicated evaluations, studies, and tests deemed to be necessary by the examiner should be performed. The Veteran's claims file should be reviewed by the examiner in conjunction with the examination. The rationale for all opinions expressed must be provided. 

The examiner is informed that the Veteran is service-connected for hypertension.

The examiner is asked to answer the following questions: 

a. Whether the Veteran has a current diagnosis of a heart disability, to include AV block with abnormal EKG? If so, is it at least as likely as not (50 percent or greater likelihood) incurred in service, caused by, or otherwise related to service?

b. If the Veteran has a current diagnosis of a heart disability, is at least as likely as not (50 percent or greater likelihood) proximately due to or, alternatively, aggravated (permanently worsened beyond the natural progression of the disease) by the service-connected hypertension?

2. Schedule the Veteran for a VA examination for his claimed tinea versicolor to determine the nature, extent, and etiology of the claimed skin disorder. Any indicated evaluations, studies, and tests deemed to be necessary by the examiner should be performed. The Veteran's claims file should be reviewed by the examiner in conjunction with the examination. The rationale for all opinions expressed must be provided. 

      The examiner is asked to answer the following question: 

Whether the Veteran has a current diagnosis of tinea versicolor? If so, is it at least as likely as not (50 percent or greater likelihood) incurred in service, caused by, or otherwise related to service?

3. Schedule the Veteran for a VA examination for his claimed condyloma to determine the nature, extent, and etiology of the claimed disorder. Any indicated evaluations, studies, and tests deemed to be necessary by the examiner should be performed. The Veteran's claims file should be reviewed by the examiner in conjunction with the examination. The rationale for all opinions expressed must be provided. 

      The examiner is asked to answer the following question: 

Whether the Veteran has a current diagnosis of condyloma? If so, is it at least as likely as not (50 percent or greater likelihood) incurred in service, caused by, or otherwise related to service?

4. Schedule the Veteran for a VA examination to evaluate the current severity of his service-connected lumbar spine strain with degenerative changes.

The Veteran's claims file should be reviewed by the examiner in conjunction with the examination. The examiner should identify and describe all current symptomatology. The examiner should provide a detailed review of the Veteran's current complaints, as well as findings as to the nature, extent, and severity of symptoms caused by the Veteran's lumbar spine disability.

A full rationale must be provided for all medical opinions given. If the examiner is unable to provide an opinion without resorting to mere speculation, he or she should explain why this is so. The examiner shall then explain whether the inability to provide a more definitive opinion is the result of a need for more information and indicate what additional evidence is necessary, or whether he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s).

5. After the above is complete, readjudicate the Veteran's claims. If any claim remains denied, issue a supplemental statement of the case (SSOC) to the Veteran and his representative. 

The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999).

This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012).




______________________________________________
A. P. SIMPSON
Veterans Law Judge, Board of Veterans' Appeals

Department of Veterans Affairs