Citation Nr: 21010941 Decision Date: 02/26/21 Archive Date: 02/26/21 DOCKET NO. 12-22 748 DATE: February 26, 2021 ORDER Service connection for a heart disorder, to include a heart murmur, is denied. Service connection for hypertension is denied. Service connection for a pregnancy related disorder and residuals, to include hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome, and preeclampsia, is denied. FINDINGS OF FACT 1. The preponderance of the evidence weighs against a finding that the Veteran’s heart murmur causes functional impairment of earning capacity. 2. The preponderance of the evidence weighs against a finding that the Veteran’s hypertension began during, manifested within one year of separation of, or is etiologically related to her active duty service. 3. The preponderance of the evidence weighs against a finding that the Veteran has a current diagnosis, or any residuals associated with her in-service pregnancy. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a heart disorder, to include a heart murmur, have not been met. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. 2. The criteria for service connection for hypertension have not been met. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.303, 3.307, 3.309. 3. The criteria for service connection for a pregnancy related disorder, to include residuals, and to include HELLP syndrome and preeclampsia, have not been met. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1996 to April 1997. These claims are on appeal from a January 2009 rating decision. In January 2015, May 2017, April 2019, and July 2020, the Board remanded the claims to the Agency of Original Jurisdiction (AOJ) for additional development (to include VA examinations and opinions, as well as to offer the Veteran the opportunity to submit additional evidence) and readjudication (the Veteran requested that the AOJ review certain evidence in the first instance). All required development has been accomplished, to include specific opinions requested in connection with the July 2020 remand. Therefore, the Board finds there has been substantial compliance with its prior remand directives and the claims are now properly returned to the Board. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Although the Veteran originally requested a hearing before the Board in connection with her claim, she failed to appear at one in February 2013. Since then, she has not provided good cause for her failure to appear and she has not requested a new hearing be scheduled. Therefore, the Board finds her hearing request has been withdrawn. Although all the evidence of record has been thoroughly reviewed, only the most relevant and salient evidence is discussed below. See Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000). The analysis in this decision focuses on what the evidence shows or fails to show with respect to the matters decided herein. The Veteran should not assume that pieces of evidence not explicitly discussed herein have been overlooked. See Allday v. Brown, 7 Vet. App. 517, 527 (1995). Service Connection Service connection may be established for disability due to a disease or injury that was incurred in or aggravated by active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may also be granted for any disease initially diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In general, in order to prevail on the issue of service connection the evidence must show: (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). Certain chronic diseases will be presumed related to service if they were shown as chronic (reliably diagnosed) in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service, with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013); Fountain v. McDonald, 27 Vet. App. 258 (2015); 38 C.F.R. §§ 3.303, 3.307, 3.309. Hypertension is such a disability. Additionally, a disability that is proximately due to, or results from, another disease or injury for which service connection has been granted, will be considered part of the original disorder. 38 C.F.R. § 3.310(a). Moreover, 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). In the absence of proof of a current disability, there can be no valid claim for service connection. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (finding service connection presupposes a current diagnosis of the condition claimed). The requirement that a current disability be present 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... even though the disability resolves prior to the Secretary’s adjudication of the claim.” McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). 1. Service connection for a heart murmur The Veteran is claiming service connection for a heart murmur; she has indicated she was treated for a murmur and palpitations during service and that she still suffers from palpitations. See September 2008 and February 2010 statements. A November 1995 enlistment examination reflects a heart murmur was detected on examination. In June 1996, she complained of palpitations and a tight chest during exercise; an electrocardiogram was performed, and the results were normal. The March 1997 separation examination is negative for a diagnosis of a heart condition and the Veteran denied cardiac symptoms on separation. The Veteran was afforded an August 2020 heart examination and the examiner concluded that while there was a flow murmur, this is benign and a normal finding in young adults and is not indicative of valvular heart disease. Although the Veteran complained of nonspecific palpitations, this is not a diagnosis and is a subjective complaint; she has no cardiac arrhythmias or other abnormalities that would cause palpitations. Based on the foregoing, the Board finds service connection must be denied because the Veteran does not have a diagnosed heart disorder. See Brammer, 3 Vet. App. 223, 225 (1992) (finding service connection presupposes a current diagnosis of the condition claimed). Further, a symptom (in this case, a heart murmur) is not in and of itself a disability for which service-connection may be granted service connection absent evidence of functional impairment in earning capacity. See Saunders v. Wilkie, 886 F.3d 1356, 1367-68 (Fed. Cir. 2018). However, the Veteran has not claimed, and the evidence does not suggest that her heart murmur and palpitations have risen to this level of severity. Thus, service-connected is not warranted. As discussed above, the Veteran was provided an extensive examination that revealed she does not have a diagnosable heart condition. While the August 2015 opinion indicates the heart murmur began in service because it was documented there, and the August 2020 opinion indicates it preexisted service, this is inconsequential. The Board is basing its denial on the fact that the Veteran does not have a diagnosed disability for VA purposes; thus, any consideration as to a nexus, whether on a direct basis or on the basis of aggravation, is moot. Although the Veteran is competent to report symptoms, such as heart palpitations, she is not competent to report that she has a diagnosed heart condition, as this requires specialized medical knowledge or training and is not susceptible to lay observations. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011); see Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Consideration has been given to the benefit of the doubt doctrine; however, as the preponderance of the evidence is against the Veteran’s claim, it is not applicable. See 38 U.S.C. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). 2. Service connection for hypertension In her August 2008 claim for compensation, the veteran indicated her hypertension began during her active service in March 1997. She has claimed she had elevated blood pressure during her first pregnancy which continued after she delivered the child; she stated that she had high blood pressure again with her second pregnancy, causing her to prematurely deliver her second child and experience additional complications. See February 2010 Notice of Disagreement (NOD). On entrance to service, the Veteran’s blood pressure was 122/74. In June 1996, two readings were taken which were 136/76 and 130/72; in October 1996, her blood pressure was 121/76. At a March 1997 dental examination her blood pressure measured 145/88. At separation, her blood pressure was 129/81 and the separation examination noted the Veteran had a routine pregnancy without complications except for elevated blood pressure which was under workup. The Veteran gave birth to her first child in June 1997, two months after separating from active duty service. Unfortunately, the records from the private hospital where she gave birth as those records are destroyed after ten years. See May 2015 Report of General Information. In a March 2002 annual gynecological health history form, the Veteran denied ever having high blood pressure. Under the pertinent boxes relating to pregnancy history, when asked to list complications, such as high blood pressure, she did not report any complications with her June 1997 delivery. At an October 2004 gynecological appointment to restart birth control, the Veteran’s blood pressure measured 120/70 and she indicated she was not on any medications. In a May 2005 gynecological health history form, the Veteran indicated she was attending this appointment because she was pregnant. She denied ever having high blood pressure; under the pertinent boxes relating to pregnancy history, when asked to list complications, such as high blood pressure, she did not report any complications with her June 1997 delivery. At eight separate appointments from May to November 2005, the Veteran’s blood pressure readings were normal. At a November 16, 2005, gynecological appointment, her blood pressure measured 168/102 and preeclampsia was suspected. She was then admitted to the hospital with a blood pressure reading of 154/90, and it was noted that based on her blood pressure reading and laboratory results (proteinuria on urine dipstick), her symptoms were consistent with preeclampsia. An HELLP panel was positive and due to possible worsening of HELLP syndrome, she was induced and had a vaginal delivery of a preterm live male infant weighting four pounds, six ounces. The discharge summary notes severe preeclampsia with HELLP syndrome. In November 2005, the Veteran sought treatment with her primary care physician for high blood pressure; it was noted she was four days post-partum with HELLP syndrome and that her liver enzymes had improved. Her blood pressure was 140/108 and the physician prescribed Labetalol. At a follow-up appointment one week later, her blood pressure was 154/90. The available records from this physician do not indicate when the medication was discontinued; however, a December 2006 treatment note does not mention any ongoing complaints or medical treatment for high blood pressure, and at that appointment, her blood pressure was 120/70. A January 2006 private gynecological appointment note indicates the Veteran presented for post-partum follow-up; she indicated she was seeing her primary care provider regarding blood pressure and indicated she took Labetalol. At that appointment, her blood pressure reading was 130/80. At a February 2007 gynecological appointment, the Veteran reported her current medications included vitamins and depoprovera (birth control); her blood pressure measured 128/78. At an April 2008 gynecological appointment, the Veteran’s blood pressure measured 112/70; she reported her current medications as depoprovera. In June 2013, the Veteran presented to her gynecologist to establish prenatal care due to a recent positive urine pregnancy test; her blood pressure reading was 112/68. It was noted the Veteran had a history of pregnancy induced hypertension with her second pregnancy; the only medication listed was Diflucan (a medication used to treat fungal infections). In an accompanying health history form, the Veteran did not report any complications associated with her 1997 pregnancy but did report high blood pressure and HELLP syndrome associated with her 2005 pregnancy. A January 2014 hospital discharge summary reflects the Veteran presented to the hospital with an episode of vaginal bleeding and it was noted that her prenatal course had been unremarkable up to that time. She had a spontaneous vaginal delivery of a term life female; her postpartum course was unremarkable, and her only discharge medication was Percocet for pain. At an October 2014 primary care appointment, the Veteran voiced complaints of gastroesophageal reflux disorder symptoms, stress, and back pain; her blood pressure was 120/78. At an August 2015 examination, the Veteran’s blood pressure readings were: 144/89, 142/88, and 137/86. She indicated at this examination that she was monitored for high blood pressure during her first pregnancy but was never started on medication. She stated in 2005 she developed hypertension and was on medication for about a year; she changed her diet and exercised more frequently controlling her blood pressure and had not been on medication since then. A November 2016 primary care appointment note indicates the Veteran presented for follow-up of elevated blood pressure; it was noted she was placed on medication and that she had a forty-pound weight gain over the past few years. Diagnoses were essential hypertension and obesity. An August 2020 examiner determined it was less likely than not (less than a 50 percent probability) that the Veteran’s hypertension began during or was etiologically related to her active service, reasoning that while there were slightly elevated blood pressure readings in service treatment records, there was no diagnosis of hypertension during or at separation from service. The examiner further noted the Veteran was diagnosed with hypertension during her pregnancy in 2005. Based on the foregoing, the Board finds the preponderance of the evidence weighs against a finding that the Veteran’s hypertension began during, manifested within one year of separation from, or is otherwise etiologically related to her active duty service. Initially, a diagnosis of hypertension must be confirmed by readings taken two or more times on at least three different days. 38 C.F.R. § 4.104, Diagnostic Code 7101. The term hypertension means that the diastolic blood pressure is predominantly 90mm. or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160mm. or greater with a diastolic blood pressure of less than 90mm. Id. Thus, the Veteran’s in-service blood pressure readings do not meet the diagnostic criteria required for a diagnosis of hypertension. Next, the Board also finds the preponderance of the evidence weighs against a finding that the Veteran’s hypertension manifested within one year of separation from active service. First, the Board finds the Veteran’s statements have been inconsistent, and therefore, affords them little probative value. See Caluza v. Brown, 7 Vet. App. 498, 510-11 (1995) (holding that in weighing credibility, VA may consider, among other things, inconsistent statements, internal inconsistency, and consistency with other evidence of record). In a September 2008 claim form she stated she was again diagnosed with hypertension during her second pregnancy, suggesting it had resolved after her first pregnancy, and contradictorily stated in her February 2010 NOD that her hypertension continued after giving birth to her first child. Significantly, while the Veteran may have had elevated blood pressure readings associated with her first pregnancy, and although those hospital records are not available, the Board finds the most probative evidence is the Veteran’s health history forms to her gynecologist in which she did not report a history of high blood pressure associated with her first pregnancy. Courts have recognized how medical history recounted in the course of medical evaluation and treatment is especially probative (trustworthy) because the declarant has inherent incentive to give the most accurate history to, in turn, receive the best or most appropriate medical care. See Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (holding that statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive proper care). Thus, the Board finds if the Veteran had a history of high blood pressure during her first pregnancy, aside from some elevated readings, that she would have reported this to her gynecologist in connection with her second pregnancy. Here, the Board finds the Veteran’s statements to her treating providers to be more probative than her subsequent statements made in the course of her disability compensation claims. See Rucker, 10 Vet. App. at 73. Finally, the Board finds that there is no etiological relationship between the Veteran’s currently diagnosed hypertension and her active service. The earliest competent evidence of a diagnosis of hypertension is in 2005, in connection with the Veteran’s second pregnancy, and more than eight years following her separation from active duty service, which weighs against her claim. See Mense v. Derwinski, 1 Vet. App. 354, 356 (1991) (holding that the passage of many years between discharge from active service and the continuity of symptomatology or medical documentation of a claimed disability are factors that tend to weigh against a claim for service connection). Significantly, at gynecological appointments in October 2004 and from May to November 2005, her blood pressure readings were normal. The first elevated blood pressure reading is on November 16, 2005. Thereafter, the Veteran was prescribed medication for her high blood pressure; it is unclear the date she discontinued the medication, but a December 2006 treatment note with the same provider does not make any mention of high blood pressure or medication for the same. Moreover, gynecological notes indicate a history of pregnancy induced hypertension. The Veteran’s current diagnosis of essential hypertension was rendered sometime in approximately 2016, according to a November 2016 follow-up note from her primary care provider. Unfortunately, this single treatment note was submitted by the Veteran, but she did not submit prior treatment notes which indicate the actual date of onset. However, at her August 2015 examination for compensation purposes, her blood pressure readings were not sufficient to render a diagnosis of hypertension. See 38 C.F.R. § 4.104, Diagnostic Code 7101. Thus, the earliest evidence of a continuous diagnosis of hypertension is in approximately 2016, which is nearly two decades following the Veteran’s separation from active duty, which weighs against her claim. See Mense, 1 Vet. App. at 356. The Board acknowledges the Veteran’s statements that she believes she has had hypertension during and since service; however, the Veteran is not competent to report that she has a diagnosis of hypertension, as this requires specialized medical knowledge or training and is not susceptible to lay observations. See Kahana, 24 Vet. App. at 435; see Jandreau, 492 F.3d at 1377 n.4. Notably, she has not claimed that she took any blood pressure readings herself during the time in question; her belief is based on lay observation alone and is in direct contradiction to the medical evidence of record. Based on the foregoing, the Board finds service connection for hypertension must be denied. As the preponderance of the evidence weighs against the Veteran’s claim, the benefit of the doubt doctrine is not applicable. See 38 U.S.C. § 5107(b); see also Gilbert, 1 Vet. App. at 56. 3. Service connection for a pregnancy related disorder and residuals (to include preeclampsia and HELLP syndrome) The Veteran is claiming service connection for pregnancy related disorders and residuals. Specifically, she has claimed HELLP syndrome and preeclampsia and claimed her HELLP syndrome began in November 2005. See August 2008 Claim; see also September 2008 Statement. She has also stated she was diagnosed with preeclampsia during her first pregnancy and that the diagnosis during her second pregnancy is not a coincidence. See June 2020 VA Form 9. More recently, she has indicated that she has endometriosis which required surgery. See November 2019 Statement. The Veteran became pregnant during her first period of active duty service; she separated from service in March 1997 and it was noted she had elevated blood pressure. She gave birth to her first child in June 1997. As noted above, private hospital records associated with that pregnancy are unavailable. In a March 2002 annual gynecological health history form, under the pertinent boxes relating to pregnancy history, when asked to list complications, she did not report any complications with her June 1997 delivery. In a May 2005 gynecological health history form, the Veteran indicated she was attending this appointment because she was pregnant. Under the pertinent boxes relating to pregnancy history, when asked to list complications, such as high blood pressure, she did not report any complications with her June 1997 delivery. On November 16, 2005, the Veteran presented to her gynecologist with high blood pressure and was admitted to the hospital; the hospital summary notes that the Veteran’s laboratory results (proteinuria on urine dipstick) and high blood pressure symptoms were consistent with preeclampsia. An HELLP panel was positive and due to possible worsening of HELLP syndrome, she was induced and had a vaginal delivery of a preterm live male infant weighting four pounds, six ounces. The discharge summary notes severe preeclampsia with HELLP syndrome. In November 2005, the Veteran sought treatment with her primary care physician for high blood pressure; it was noted she was four days post-partum with HELLP syndrome and that her liver enzymes had improved. Notably, the Veteran had a spontaneous vaginal delivery in January 2014 with her third child and the prenatal course was uncomplicated. There is no evidence of any pregnancy related disorders. In August 2020, a medical professional reviewed the Veteran’s lay statements and medical evidence and found it was less likely than not (less than a 50 percent probability) that the Veteran had a pregnancy related disorder which was related to service; specifically, the medical professional determined there was no diagnosis of any pregnancy related disorder or residuals and noted that all the Veteran’s pregnancies resolved without chronic disability or residual. Based on the foregoing, the Board finds that service connection for pregnancy disorders and residuals must be denied as there is no current diagnosis of any pregnancy related disorder or any residuals. Notably, there have been no diagnoses rendered of HELLP or preeclampsia during the appeal period and the available records do not demonstrate the Veteran continued to experience any residuals from these complications. Significantly, during the appeal period, the Veteran gave birth to her third child without any complications. Here, the claim is being denied because there is no current disability; thus, any findings related to a nexus or etiology are moot. See Brammer, 3 Vet. App. at 225 (finding service connection presupposes a current diagnosis of the condition claimed). The Board acknowledges the Veteran’s statements that she believes she has residuals of HELLP syndrome; however, the Veteran is not competent to report that she has a diagnosis or residuals of any pregnancy disorder, as this requires specialized medical knowledge or training and is not susceptible to lay observation. See Kahana, 24 Vet. App. at 435; see Jandreau, 492 F.3d at 1377 n.4. Consideration has been given to the benefit of the doubt doctrine; however, as the preponderance of the evidence is against the Veteran’s claim, it is not applicable. See 38 U.S.C. § 5107(b); see also Gilbert, 1 Vet. App. at 56. Additional Considerations The Board acknowledges the Veteran’s statements in her February 2010 VA Form 9 that she was “given several injections of Lord knows what” during service and that she spent time overseas in Guam for several months “being exposed to who knows what,” the Board finds these statements do not support any theory of service connection nor do they require that VA obtain any opinions. Here, the claims for a heart disorder (to include a heart murmur) and pregnancy related disorders and residuals (to include preeclampsia and HELLP syndrome) were denied on the basis that there is no current disability or diagnosis; thus, any theory as to a nexus is moot. Additionally, under current case law, such bare assertions standing alone do not suffice to trigger the duty to obtain an opinion considering these alleged theories.  See Waters v. Shinseki, 601 F.3d 1274, 1278 (Fed. Cir. 2010) (“Since all veterans could make such a statement, this theory would eliminate the carefully drafted statutory standards governing the provision of medical examinations and require the Secretary to provide such examinations as a matter of course in virtually every veteran’s disability case.  If Congress had intended that requirement, presumably it would have explicitly so provided.”).  Jennifer White Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board O'Connell, Jessica L. 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.