Citation Nr: 21045534 Decision Date: 07/26/21 Archive Date: 07/26/21 DOCKET NO. 17-65 769 DATE: July 26, 2021 ORDER Service connection for hypertension, to include as secondary to service-connected gout and/or right ankle ligament disruption with residual laxity (right ankle disability), is denied. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that the Veteran's hypertension began during his first period of active service, within one year of his separation from active service, or is otherwise causally or etiologically related to an in-service injury or disease. 2. The preponderance of the evidence is against finding that the Veteran's pre-existing hypertension was aggravated during his second period of active service, nor was it caused or aggravated by his service-connected gout or right ankle disability. CONCLUSIONS OF LAW 1. The criteria for service connection for hypertension during the Veteran's first period of active service has not been met. 38 U.S.C. §§ 1110, 1111, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 2. The criteria for service connection for pre-existing hypertension during the Veteran's second period of service, to include as secondary to his service-connected gout and/or service-connected right ankle disability, have not been met. 38 U.S.C. §§ 1110, 1111, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.306, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served in the U.S. Army on active duty from July 1976 to July 1979 and from January 2003 to July 2005. In addition, he served approximately 23 years of inactive duty with the United States Army Reserve. The Veteran testified before the undersigned Veterans Law Judge in October 2019. Regarding the claim on appeal, he stated that he developed high blood pressure during his first period of service, in that he remembers being placed on hypertension medication in the 1970s. See also statements in July 2011 VA examination report. The Veteran entered his second period of service with hypertension. He testified during his Board hearing that he believed his hypertension was aggravated during this service and/or aggravated by his service-connected gout disability. Regarding his gout theory, the Veteran stated that his private physician told him that pain caused his blood pressure to be elevated, and that a VA doctor told him that there was a possible correlation. See Board hearing transcript, pgs.11-12. The Veteran did not testify that he believed his hypertension developed secondary to his service-connected right ankle disability. However, he raised this theory in July 2010, when he argued that the constant pain in his right ankle caused his blood pressure to be elevated and out of control. This theory was denied in a July 2011 rating decision; however, the Board finds that it should be examined. Although the Veteran has limited his secondary service connection claim to gout, the Board has a duty to review all service-connected disabilities that may aggravate the Veteran's hypertension - to include his right ankle disability. The Veteran currently has a combined disability rating of 70 percent. The Veteran's appeal has been remanded twice, in March 2020 and April 2021, for a medical opinion as to whether the Veteran's pre-existing hypertension was aggravated by active service or secondary to his service-connected gout. In this regard, the Board feels compelled to address a recent letter from the Veteran regarding VA's medical examination process. Specifically, the Veteran expressed his anger and frustration toward the person who examined him in August 2020. In essence, he appears to state that the August 2020 examiner was negligent in his consideration of the Veteran's medical history and his answers to questions, lacked common sense and was a hypocrite ("I am questioning the hypocrisy of the Medical Examiner"). He stated that he was not asking to change anything (in terms of the evidence in the claims file) or that he be reexamined by another physician. He stated that he was asking that the Board launch an investigation into VA's medical examiners as he believed that he was not the only one to experience "this type of negligence and hypocrisy" during VA examinations. The Board sincerely regrets the Veteran had this experience. However, the Board is an appellate body. It only requests medical opinions when it needs medical guidance as to an issue on appeal. It has no control over the assignment of a specific medical provider, how the examiner performs his/her examination (unless the examination is clearly deficient in regards to the Board's remand instructions) nor does it have the authority to launch an investigation of any of the medical providers utilized by VA. It simply does not have jurisdiction. The Board hopes that by noting the Veteran's complaints in this opinion, light is shown on this situation such that further action may be undertaken by the appropriate body. Further, the Veteran is encouraged to report any perceived misconduct to the Veterans Health Administration (VHA). SERVICE CONNECTION FOR HYPERTENSION 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 active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Generally, to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of a disease or injury, and (3) a nexus, or link, between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection for certain chronic diseases, including hypertension, will also be presumed if they manifest to a compensable degree within one year following active military service or are shown by evidence of continuity of symptomatology. Service connection may also be granted on a secondary basis for a disability that is proximately due to a service-connected condition. 38 C.F.R. § 3.310(a). Service connection is also possible when a service-connected disability has aggravated a claimed condition, but compensation is only payable for the degree of additional disability attributable to the aggravation. Allen v. Brown, 7 Vet. App. 439 (1995). The law provides that a pre-existing disease or injury will be considered to have been aggravated by military service where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 U.S.C. § 1153; 38 C.F.R. § 3.306(a). Aggravation may not be conceded where the disability underwent no increase in severity during service based on all the evidence of record pertaining to the manifestations of the disability prior to, during, and after service. 38 U.S.C. § 1153; 38 C.F.R. § 3.306(b). 1. Direct Service Connection - Active Duty from July 1976 to July 1979 A review of the Veteran's treatment records during his first period of service do not reflect a diagnosis of hypertension or symptomatology that can be associated with this disorder. When the Veteran entered service, hypertension was not noted on his service entrance examination, and his blood pressure was reported as being 120/72 (systolic pressure/diastolic pressure). On report of medical history forms dated in June 1976 and June 1979, the Veteran denied having (currently or in the past) high blood pressure and was also denied taking any medications. See also January 1979 treatment records ("No meds"). His blood pressure was noted as 120/70 on his June 1979 separation from service medical examination form. Post-initial service medical records reflect the Veteran's blood pressure as being 130/94 in July 1985; and the Veteran denied having high blood pressure on his medical history form. A September 1990 record documents a blood pressure reading of 120/80, without any defects or diagnoses noted. Additionally, although the Veteran was reported as having a blood pressure reading of 158/92 in September 1994, he denied having hypertension, stated he was in good health and denied taking medications. The first indication of the Veteran having hypertension that the Board found is documented in a Medical Evaluation Board Proceedings record that notes the approximate date of origin as 2000. See April 2005 medical record; however, see also January 2005 medical record (the Veteran went on medication in 2000). The first actual high blood pressure readings the Board located are documented in an April 2002 report of medical examination. At that time, the Veteran's blood pressure readings were 174/110 and 164/96. Under the recommendations section of the examination report, the Veteran's examiner appears to state that the Veteran needed to be seen as soon as possible for uncontrolled blood pressure ("reads FM ASAP for controlled [ ] BP (noncompliant)"). Although the Veteran testified that he took medication for high blood pressure sometime in the 1970s, his service and post-service medical records document that even though he may have taken medication at some point for some other disorder, it was not for hypertension and was not during his initial period of active duty. Given this evidence, the Board finds that service connection for hypertension on a direct basis for the Veteran's initial period of active duty must be denied. 2. Aggravation - Active Duty from January 2003 to July 2005 The Veteran has not alleged that his hypertension manifested during his second period of service. Rather, he has reported that he suffered with hypertension for many years prior to January 2003. As such, one theory of entitlement to service connection before the Board is whether the Veteran's pre-existing hypertension was aggravated during his second period of service. Medical records dated in January 2005 indicate that the Veteran started taking medication for high blood pressure in 2000. Medical records in the claims file dated from January 2003 to July 2005 reflect the Veteran's hypertension as being either poorly controlled or uncontrolled, with questionable compliance with medication. For example, records dated in 2003 reflect blood pressure readings of: 180/120, 170/120, 174/118, 150/110, 134/100, 146/110, 158/108, 140/90, 154/104, 156/104, and 150/100. See records dated from March 2003 to December 2003. One record, dated in March 2003, reflects the Veteran's blood pressure as being 180/120 with the Veteran explaining to his medical provider that he had not taken his blood pressure medication for 3 weeks. December 2003 records note that the Veteran's blood pressure medication was not working and that his blood pressure was still high, and his medication being lowered because Veteran reported it made him tired. Records dated throughout 2004 reflect blood pressure readings of 148/110, 160/118, 158/116, 144/102, 134/94, 130/90, 142/100, and 166/97. See records dated from January 2004 to October 2004. February 2004 records document that the Veteran's hypertension was uncontrolled. Subsequent records reflect that the Veteran stopped taking blood pressure medication because it caused headaches and did not make a difference. See records dated in July 2004. Notably, records dated prior to the Veteran's second period of service reflect the Veteran as having similarly elevated blood pressure readings. For instance, an April 2002 report of medical examination reveals blood pressure readings of 174/110 and 164/96, with the Veteran taking medication. A July 2002 PULHES document reflects that Veteran's high blood pressure being uncontrolled due to noncompliance with his medication. Records dated after the Veteran's second period of service note blood pressure reading of 150/100, 130/88, and 135/92. See records dated in August 2005. August 2005 records reflect that the Veteran had stopped taking medication on his own because it did not make a difference in his blood pressure, that he was out of medication. His hypertension was again noted to be uncontrolled with blood pressure readings of 147/100, 142/100, 140/106, 134/100. Medical records dated in late-2005 and 2006 show readings of 126/81, 130/100, 158/102, 146/100, 156/100, 139/88, 136/101. Records dated in 2007 and 2008 note blood pressure readings of, for example, 143/86, 144/97, and 140/79. Thus, the Veteran's medical records reveal that the Veteran's hypertension was elevated before his second period of service, during service and after he separated from service. The medical question this leads to is whether the elevation of the Veteran's hypertension in service constituted an aggravation of the disorder. In answering this question, the Board finds that the most pertinent and probative evidence regarding the issue of aggravation is against the Veteran's claim. The Veteran was examined in February 2017. The examiner obtained a history from the Veteran and reviewed his medical records, and thereafter completed a hypertension Disability Benefits Questionnaire (DBQ). She noted that on the day of the examination, the Veteran blood pressure readings were 148/92 and 146/94. After citing to pertinent evidence that she considered and relied upon, she provided a medical opinion as to whether the Veteran's hypertension was aggravated during his second period of service. In essence, she opined that the Veteran had hypertension that unmistakably existed prior to service and was not aggravated beyond its natural progression by an in-service event, injury, or illness (to include the Veteran's uncontrolled blood pressure in service). The Veteran was also afforded a VA examination in August 2020. The doctor examining the Veteran reported that his hypertension was diagnosed in 1999, per the Veteran's medical history. His blood pressure was taken and noted to be 164/98, 139/82, and 130/82, with the Veteran reporting that he was on the medication Azor. After discussing his medical history and reviewing the evidence, the doctor completed a hypertension DBQ. He ultimately opined that the Veteran's hypertension clearly and unmistakably existed prior to service and could not be shown to be aggravated beyond its natural progression by active service from January 2003 to July 2005. He stated that there were no medical records that he found that supported an aggravation nexus. The Board finds the February 2017 and August 2020 medical opinions to be highly credible and persuasive in that they are based upon the evidence of record by medical professionals with experience and expertise in the medical community. In addition, they are unrebutted. The Veteran argues error in that the VA examiners (particularly the doctor who evaluated him in August 2020) were essentially incompetent and hypocrites in not considering/discussing in their opinions commonsense factors such as one's blood pressure becoming elevated when working extremely long hours in an extremely stressful job or pain (especially repetitive pain) related to gout can cause one's blood pressure to elevate. The Veteran also essentially argues that the correct number of gout attacks he has had each year were not correctly considered by the examiners since many of his visits to a VA Hospital for care were not documented. The Board finds that the lack of documentation of such considerations noted by the Veteran are not obvious errors in the DBQs or medical opinions upon which they were based. The DBQs contain citations to the evidence that the examiners found to be particularly pertinent. However, the list is not exhaustive, and the examiners clearly took into consideration the Veteran's discussions as they were part of those discussions. Simply because commonsense principles were not specifically noted in the DBQs or medical opinions does not mean they were not considered with all other evidence of record. Additionally, the Veteran's aggravation theory based upon the commonsense principles noted above need not have been documented in the reports or opinions since they are essentially arguments made by the Veteran as to why he believes his hypertension was aggravated during his second period of service or by his service-connected gout. Lastly, such may not have been included by the examiners because a temporary blood pressure elevation due to stress or pain is not the medical equivalent to a finding of "aggravation" per VA regulations, which is what the examiners were ask to provide in the medical nexus opinions. Unfortunately, the Veteran is not competent to provide a medical nexus opinion on the issue of direct aggravation of his hypertension during his second period of service as he has not been shown to have any specialized medical knowledge or training to provide a nexus opinion as to this issue. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Therefore, service connection for hypertension based upon a direct theory of aggravation must be denied. 3. Aggravation - Secondary Service Connection (Gout and Right Ankle) The Veteran is service-connected for, among other things, (1) interval gout (to include right knee and right ankle/foot)(gout) and (2) right ankle ligament disruption with residual laxity (claimed as right foot and ankle)(right ankle). His final theory of entitlement to service connection is that his service-connected gout has aggravated his nonservice-connected hypertension. As this is a secondary service connection claim, the Board has also considered whether the Veteran's service-connected right ankle disability has aggravated his nonservice-connected hypertension. Although post-service medical records in the claims file reveal the Veteran's treatment for hypertension, gout, and right ankle pain/strain, they do not reflect any medical evidence of the existence of a relationship between the Veteran's hypertension and gout or his hypertension and his right ankle pain/strain. Turning to the VA medical opinions of record, during a June 2011 VA examination, the Veteran's blood pressure was recorded as 150/100, 146/100 and 148/100 and he reported being on Micardis HCT. The examiner noted that the Veteran opined that his ankle injury in 2003 resulted in his blood pressure becoming uncontrolled and having serious side effects. After reviewing the Veteran's records, obtaining a medical history and conducting a physical examination, the doctor essentially opined that the Veteran's hypertension was not related to his right ankle disability because he was diagnosed with hypertension in 2000, whereas he was diagnosed with a right ankle injury in 2003. In his opinion, it was medically impossible to relate the conditions because the Veteran's hypertension occurred several years before his right ankle injury. He stated that pain from the Veteran's ankle injury could result in an elevation of blood pressure, but he did not indicate that this would be other than a temporary elevation. He also opined that an elevation in blood pressure would not result from the side effects from the medications used to control blood pressure. As for the August 2020 medical opinion referenced above, the examining medical doctor opined that the Veteran's hypertension had no direct correlation, nor was it the result of the Veteran's interval gout. He stated that there were no medical records found which supported such a nexus. He also stated that a gout condition in and of itself is not often associated with hypertension. Further, he reported that there is no pathophysiological connection between gout and hypertension. The Board remanded the Veteran's claim to address why the Veteran's gout condition might not be an exception to the general rule that gout "in and by itself is not often associated" with hypertension. In response, the same medical doctor who examined the Veteran in August 2020 provided an addendum stating that there is no association or correlation between gout and hypertension. He explained that the etiology of hypertension is usually idiopathic in greater than 90 percent of the time. Additionally, he stated that there were no records found supporting aggravation of the Veteran's hypertension. For the same reasons set forth above, the Board finds the unrebutted June 2011 and August 2020 medical opinions to be highly persuasive and probative. As for the Veteran's statements and Board hearing testimony, the Board finds that just as he is not competent to provide a medical nexus opinion on the issue of direct aggravation of his hypertension during his second period of service, he is not qualified to provide an opinion as to whether one medical disorder is related to another. In sum, the Board has considered all evidence of record and finds that the preponderance of the evidence is against the Veteran's claim that his hypertension has been aggravated by his service-connected gout or service-connected right ankle disability. The appeal for service connection on a secondary basis for hypertension must be denied. H.M. WALKER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board P. Talpins 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.