Citation Nr: 22017405 Decision Date: 03/25/22 Archive Date: 03/25/22 DOCKET NO. 17-22 975 DATE: March 25, 2022 ORDER Entitlement to service connection for hypertension, to include as secondary and/or aggravated by service-connected post-traumatic stress disorder (PTSD) and/or its medications, is denied. FINDING OF FACT The record shows a May 2017 VA Routine Blood-Pressure Check states the Veteran was currently on anti-hypertensive medication, he claimed to be compliant with a current blood-pressure-treatment plan and he was assessed with controlled hypertension; the evidence of record otherwise shows hypertension was not incurred during active service, it is not caused by an event, injury or illness occurring in active service, it is not proximately due to, the result of or made worse to any degree by service-connected PTSD and/or its medications, and it did not manifest to a compensable degree within 1 year of separation from active service. CONCLUSION OF LAW The criteria for service connection for hypertension, to include as secondary and/or aggravated by service-connected PTSD and/or its medications, have not been met, nor are they presumed to be. 38 U.S.C. §§ 1110, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2020). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Army from April 1991 to September 1992. Service connection will be granted if the evidence demonstrates that a current disability resulted from a disease or injury incurred in active service or that a preexisting injury or disease was aggravated by active service. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303(a) (2020). Establishing service connection generally requires: (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 in or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Additionally, service connection may be granted on a secondary basis for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Moreover, service connection of a nonserviceconnected disease or injury will be established if an increase in severity of the nonserviceconnected disability is shown to be proximately due to or the result of a service-connected disease or injury and not due to the natural progress of the nonserviceconnected disease or injury. 38 C.F.R. § 3.310(b). The evidence must show (1) a current disability exists and (2) the current disability was the (a) proximately caused by or (b) proximately aggravated (worsened in severity to any degree) by a service-connected disability. Id.; Allen v. Brown, 7 Vet. App. 439, 448-49 (1995). Certain chronic diseases may be service connected on a presumptive basis if manifested to a compensable degree in a specified period of time post-service. 38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. That period is usually one year. 38 C.F.R. § 3.307(a)(3). 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. 38 C.F.R. § 3.303(b). Under 38 C.F.R. § 3.303(b), an alternative method of establishing an in-service disease or injury and a nexus for chronic diseases is through a demonstration of continuity of symptomatology. Barr v. Nicholson, 21 Vet. App. 303 (2007); see Savage v. Gober, 10 Vet. App. 488, 495-97 (1997); see also Clyburn v. West, 12 Vet. App. 296, 302 (1999). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Savage, 10 Vet. App. at 495-96; see Hickson, 12 Vet. App. at 253 (lay evidence of in-service incurrence sufficient in some circumstances for purposes of establishing service connection); 38 C.F.R. § 3.303 (b). Entitlement to service connection for hypertension, to include as secondary and/or aggravated by service-connected PTSD and/or its medications. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2016 rating decision denying this claim. The claim was addressed twice before by the Board, in the first instance of which, the Board remanded this claim and 8 others for new examinations. However, the claim for service connection for hypertension was not addressed by the Remand, no specific directives were made for a new examination and, consequently, no new examination was conducted. Whether it was intended there be no examination or it was not conducted due to an oversight, there has been no prejudice to the Veteran, as the Board's September 2021 Remand directed a new examination be conducted due to the prior examination's deficiencies. The new examination with opinions is now of record. VA defines hypertension as diastolic blood pressure of predominantly 90mm or greater, which 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. Isolated systolic hypertension is defined as systolic blood pressure of predominantly 160mm or greater with a diastolic blood pressure of less than 90mm. Id. The service treatment records (STRs) show in the March 1991 enlistment examination, the treatment provider found the Veteran's vascular system to be normal. He recorded the Veteran's blood pressure at 110/60. Additionally, the Veteran denied past or current high blood pressure and dizziness or fainting spells. In the August 1992 separation examination, the treatment provider found a normal vascular system. The Veteran's blood pressure was 122/74. The Veteran denied past or current high blood pressure and dizziness or fainting spells. Treatment notes during active service show the following blood-pressure readings. April and May 1991 acute medical care notes for various complaints show blood pressure readings of 130/60, 116/72, 100/60, and 110/74. Readings for September 1991 were 120/70, October 1991: 116/69, January 1992: 112/72, January or February 1992: 130/80, February 1992: 112/72, 118/80, 108/73, 120/72, 130/68, and 120/74, March 1992: 128/72, April 1992: 120/70, and July 1992: 118/76 and 118/82. The post-active-service record shows the Veteran underwent a VA examination for hypertension in July 2016, in which the examiner stated at the outset the Veteran does not now have or has ever been diagnosed with hypertension. He noted the Veteran's report of having pre-hypertension based on STRs documenting a diastolic blood-pressure reading in the 90s. He further stated he was concerned with receiving medications in the future which might make him hypertensive. The examiner noted 2 blood-pressure readings from different days in June 2016 of 126/78 (with a second reading of 125/75) and125/70 and that day's reading of 118/86 (second reading, 124/86), to which he added 2 more readings for the examination which provided an average of 121/84. The examiner opined it is less likely than not that the Veteran has a diagnosis of hypertension which was incurred in or caused by the blood pressures recorded during service; or is proximately due to or the result of or aggravated beyond its natural progression by PTSD due to military sexual trauma. He explained none of the blood pressures recorded on the 2507 form from 1991 92 nor the blood pressures taken for the current VA examination meet VA criteria for any diagnosis listed in the examination. He added the Veteran currently is not taking any blood-pressure medications. In May 2017, the Veteran presented to VA for a Routine Blood-Pressure Check, in which the treatment provider took a reading of 124/87, she noted the Veteran is currently on anti-hypertensive medication, noted his report of being compliant with his blood-pressure reading treatment plan, and assessed the Veteran with controlled hypertension. In a November 2016 VA primary care note, the Veteran admitted to a family history of hypertension and stroke. During a December 2017 VA primary care assessment, the Veteran reported his father and brother have diagnoses of hypertension. Additionally, on review-of-systems questioning, the Veteran denied having any hypertension. VA treatment records show the same response through to a June 2018 primary care assessment. The same denial appears in a January 2020 VA primary care note. A March 2020 VA mental health note shows the Veteran reported he discontinued a medication for anxiety and depression, as it caused high blood pressure, which he further reported as having taken a reading of 224/84. In a VA nursing outpatient note February 2021, the treatment provider noted the Veteran does not have an active prescription for anti-hypertensives. The Board in September 2021 remanded this claim for a new VA examination and opinion, as the July 2016 VA examiner based his negative opinion on the lack of diagnosis, but the Board noted in its review of the record the May 2017 VA Routine Blood Pressure Check, in which the treatment provider stated the Veteran was on anti-hypertensive medication and diagnosed controlled hypertension. Given this subsequent diagnosis, the Board directed there be a new examination with opinion. The Veteran was afforded another VA examination for hypertension in November 2021, in which the examiner stated the Veteran does not currently have a diagnosis of hypertension or isolated systolic hypertension and made no diagnosis. She noted the Veteran's reports of having been diagnosed with hypertension in 1992, but never prescribed medications. She noted the Veteran attributes all his medical issues to his reported exposure to a depleted uranium rod, belonging to a fellow soldier. He added "[n]obody knew anything about uranium at that time." The Veteran further reported he was treated for hypertension and was prescribed cholesterol medications, "which I'm not taking I'm trying to change my diet." The Veteran suspected a small hemangioma is a symptom of hypertension and also reported migraines, vertigo, fatigue, and nausea as current symptoms. He added the reason he claimed service connection for hypertension is due to his concerns of future medications being prescribed to him which might elevate blood pressure. The examiner set forth blood-pressure readings taken on different days. For the examination day, blood-pressure reading readings were 120/70, 130/78 and 120/80, as well as 2 reading on each of the other days, 114/82, 133/88 and 122/70, 130/72. She stated in her remarks there is no diagnosis because there are no findings, signs and/or symptoms to support a diagnosis. She added the Veteran does not have a diagnosis of hypertension, he has never been diagnosed with hypertension and he has never been prescribed hypertension medications. For direct service connection, the examiner opined hypertension was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event or illness. She explained by first referring to the Veteran's above reports at the beginning of the examination, indicating inconsistent statements and noting, "It was difficult to bring p[atient] back to his reported claim of HTN [hypertension]." She noted from the record no diagnosis of hypertension and further noted a list of all active-service blood-pressure readings shows none "would be in the range of HTN." She provided her own average of those readings, being at 119/68. She added, although the Veteran reported in the May 2017 VA Routine Blood Pressure Check he currently is on anti-hypertensive medications, an April 2017 VA mental health note, providing a comprehensive list of current medications, did not include any anti-hypertensive medications. She concluded by noting there is no diagnosis of hypertension in the medical evidence of record, her examination "was completely within normal limits" and the 3 days of blood-pressure readings she included in the examination "did not reveal levels diagnostic of HTN." She next opined negatively for hypertension as secondary to service-connected PTSD, to include any prescribed medications. She re-stated the above rationale. For hypertension as aggravated by service-connected PTSD, to include by its medications, the examiner, in addressing the issue of aggravation, first explained she was unable to determine a baseline level of severity of hypertension based upon medical evidence available prior to aggravation or the earliest medical evidence following aggravation by PTSD and/or its medications. She further opined negatively, explaining the Veteran does not have a diagnosis of hypertension, nor has he ever been diagnosed with hypertension. The examiner lastly opined negatively for the question of whether it is at least as likely as not that the Veteran's hypertension (1) began during active service, (2) manifested within one year after discharge from service, (3) was noted during service with continuity of the same symptomatology since service, or (4) related to an in-service injury, event, or disease. She again stated her first rationale above. The Board has carefully considered the Veteran's numerous reports to treatment providers and examiners as they appear throughout the record. The Board is well aware that lay persons are competent to report on matters observed or within their personal knowledge. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). Therefore, the Veteran is competent to provide statements of symptoms which are observable to his senses, to the extent he has here. Nonetheless, the Veteran's lay evidence in turn must be weighed against other evidence, as all relevant evidence of varying kinds must be considered. The Board must also assess the credibility, and probative value of the evidence of record in its whole. See Caluza v. Brown, 7 Vet. App. 498, 511 (1995) (the Board may consider internal consistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant). The essential contentions of the Veteran are active-service blood-pressure readings appearing in the STRs establish he incurred hypertension during active service and hypertension is caused or aggravated by service-connected PTSD and/or medications for PTSD. The Board will also note the Veteran's assertion made to the November 2021 examiner that he incurred hypertension during active service, as with all his reported disorders, when exposed to a depleted uranium rod kept by a fellow soldier as a keepsake or souvenir. Although the May 2017 VA Routine Blood Pressure Check shows the Veteran's report of being compliant with blood-pressure medications and his prescribed blood-pressure plan, the later record does not show the Veteran to be taking medications. For example, in the February 2021 VA nursing outpatient note February 2021, the treatment provider, either based on the Veteran's own report or on her review of the record, noted the Veteran does not have an active prescription for anti-hypertensives. Additionally, the Veteran specifically reported this to the November 2021 examiner. The record otherwise reflects no diagnosis of hypertension and a secondary basis of causation, to include aggravation, therefore cannot be established. The Board assigns the Veteran's lay assertions regarding symptoms and a reported diagnosis less weight. Caluza, 7 Vet. App. at 511. Based on this, the Board ascribes greater probative weight to the findings and opinions of the November 2021 examiner, who was unable to find diagnoses for hypertension in the active-service medical record or the post-active-service record. Moreover, she is a medical professional, who conducted a thorough review of the medical record and the Veteran's medical history and, for the reasons discussed above, her opinions and findings are adequate for VA adjudication purposes. See generally Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (noting that the central issue in assessing the adequacy of an opinion is whether the examiner was informed of the relevant facts in rendering a medical opinion). Lastly, as hypertension can be an early symptom long preceding the development of heart or kidney disease, it is included among those diseases which may be eligible for presumptive service connection as a "chronic disease" under 38 C.F.R. § 3.309 (a). However, consistent with the findings of the November 2021 examiner, the STRs show no reports, treatment or diagnoses of hypertension during active service and the record gives no indication of its manifestation within a year of separation from active service. Therefore, there is no possibility of identifying any continuity of symptomatology from active service through to the present. Consequently, the presumption of service connection for hypertension as a chronic disease is not available to the Veteran. The STRs do not show in-service reports, complaints, treatment, or diagnoses pertaining to hypertension. The post-service record shows in the May 2017 VA Routine Blood Pressure Check testing and an assessment of controlled hypertension. Whether based solely on the Veteran's reports or suggesting the possible existence of a current disability at the time of the filing of the claim or during or contemporary to the pendency of the claim, the record otherwise offers no evidence showing hypertension or any causal connection to active service. The July 2016 and November 2021 VA examiners found all recorded blood-pressure readings during active service and after do not support a diagnosis of hypertension. There is no evidentiary basis, direct or secondary, on which to establish a causal connection or "nexus" between any current disorder and an event, injury, illness, or exposure in active service. For the foregoing reasons and based on the medical and lay evidence of record, the Board finds no approximate balance of evidence favoring the claim for service connection. The Board has considered the benefit-of-the-doubt doctrine; however, the Board does not perceive an approximate balance of positive and negative evidence. As there is no approximate balance of the evidence for the claim, the doctrine is not applicable and the claim must be denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3. EMILY TAMLYN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board P. Franke, Associate Counsel 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.