BVA9504525 DOCKET NO. 92-11 705 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Denver, Colorado THE ISSUES 1. Entitlement to service connection for thyroidectomy. 2. Entitlement to service connection for hypertension. 3. Entitlement to service connection for chronic headaches. 4. Entitlement to service connection for residuals of a cesarean section. 5. Entitlement to service connection for major depression. 6. Entitlement to service connection for iron deficiency anemia. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD J.W. Engle, Counsel INTRODUCTION The appellant served on active duty from June 1986 to March 1987. This matter came before the Board of Veterans' Appeals (the Board) on appeal from a decision dated in March 1991 by the Denver, Colorado, Department of Veterans Affairs Regional Office (VARO). This case was remanded in December 1993 for additional development and to provide the appellant an opportunity to offer testimony in support of her claim at a personal hearing. A hearing was held before a hearing officer in March 1994 and at that time the appellant withdrew the issues of entitlement to service connection for peptic ulcer disease, refractive error, a low back disorder and cervical radiculopathy. The requested development has been completed and the case returned to the Board for appellate review. CONTENTIONS OF APPELLANT ON APPEAL The appellant contends, in essence, that a thyroid disorder was aggravated by her period of active duty. She further argues that hypertension, chronic headaches, residuals of a cesarean section, major depression, and iron deficiency anemia had their onset during her period of active duty. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991), has reviewed and considered all of the evidence and material of record in the veteran's claims file. Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that the preponderance of the evidence is against the appellant's claims to service connection for a thyroidectomy, hypertension, chronic headaches, residuals of a cesarean section, major depression, and iron deficiency anemia. FINDINGS OF FACT 1. On service entrance examination in March 1986 the appellant reported that she underwent a thyroidectomy in 1980. 2. The service medical records reflect that in July 1986 the appellant had her Synthroid prescription refilled. She reported that she had been taking Synthroid for approximately five years. 3. There are no additional reports reflecting any complaints, manifestations or findings referable to the pre-service thyroidectomy. 4. There is no objective evidence of record to establish that the preexisting thyroid disorder increased in severity during the appellant's active military service. 5. A service hospitalization report covering the period from December 27, 1986 to January 4, 1987 noted diagnoses which included pregnancy induced hypertension. A subsequent treatment report dated in February 1987 noted an elevated blood pressure reading of 136/100. 6. A private treatment report dated in December 1988 noted a blood pressure reading of 170/112. It was further noted that the appellant developed hypertension during each pregnancy with resolution after delivery until the last delivery in September 1988. 7. The service medical records reflect no complaints, findings or manifestations of a chronic headache disorder. 8. On VA examination in December 1990, a diagnosis of stress related headaches considered to be exacerbated by a refractive error was noted. 9. A private psychologist's statement dated in March 1994 noted that the appellant had been treated for probable concussive trauma of a severe nature and post traumatic headaches since June 1987. However, there was no additional information identifying the date of the alleged injury or any other information to relate the reported treatment to the appellant's period of active duty. 10. The service medical records reflect no complaints, findings or manifestations of residuals of the cesarean section performed in December 1986. 11. The first objective evidence of residuals of a cesarean section were noted on VA examination in December 1990 when a diagnosis of status post cesarean section, with a tender scar and crampy discomfort was reported. 12. The service medical records are entirely negative for any findings of a psychiatric disorder. 13. On VA psychiatric examination in December 1990 a diagnosis of major depression, single episode was noted. 14. A statement from a private psychologist dated in March 1994 noted that the appellant had been treated from June 1987 to November 1990 for depression. 15. A disease entity has not been shown to be the cause of the appellant's iron deficiency anemia. CONCLUSIONS OF LAW 1. The presumption of soundness on entry into the service as to the appellant's thyroid disorder has been rebutted by clear and unmistakable evidence. 38 U.S.C.A. § 1132 (West 1991). 2. The preexisting thyroid disorder was not aggravated by military service. 38 U.S.C.A. §§ 1131, 1153, 5107 (West 1991); 38 C.F.R. § 3.306 (1993). 3. Hypertension was not incurred in or aggravated by service nor is there a basis upon which to presume incurrence of hypertension within the initial post service year. 38 U.S.C.A. §§ 1101, 1131, 5107 (West 1991); 38 C.F.R. §§ 3.303, 3.307, 3.309 (1993). 4. A chronic headache disorder was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1131, 5107 (West 1991); 38 C.F.R. § 3.303(d) (1993). 5. Residuals of a cesarean section to include a tender surgical were not incurred in or aggravated by service. 38 U.S.C.A. 1131, 5107 (West 1991); 38 C.F.R. § 3.303(d) (1993). 6. Major depression was not incurred in or aggravated by service nor is there a basis upon which to presume incurrence of major depression within the initial post service year. 38 U.S.C.A. §§ 1101, 1131, 1137, 5107 (West 1991); 38 C.F.R. §§ 3.303, 3.307, 3.309 (1993). 7. A disorder manifested by iron deficiency anemia was not incurred in or aggravated by service. 38 U.S.C.A. 1131, 5107 (West 1991). REASONS AND BASES FOR FINDINGS AND CONCLUSION Initially, the Board finds that the appellant has submitted evidence which is sufficient to justify a belief that his claims are well grounded. 38 U.S.C.A.§ 5107(a) (West 1991) and Murphy v. Derwinski, 1 Vet.App. 78 (1990). Under pertinent law and VA regulations, service connection may be granted for disability resulting from disease or injury incurred in or aggravated while on active duty. 38 U.S.C.A. § 1131 (West 1991). Furthermore, 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." Continuity of symptomatology is required where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b) (1993). However, 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. Presumptive periods are not intended to limit service connection to diseases so diagnosed when the evidence warrants direct service connection. The presumptive provision of the statute and Department of Veterans Affairs regulations implementing them are intended as liberalizations applicable when the evidence would not warrant service connection without their aid. 38 C.F.R. § 3.303(d) (1993). I. Thyroid Disorder The service medical records reflect that the appellant reported a history of a thyroidectomy in 1980 at the age of 18. We note that with respect to the presumption of soundness to which the appellant is entitled upon entry into the service, 38 U.S.C.A. § 1132 (West 1991), in pertinent part, provides as follows: For the purposes of section 1131 of this title, every person employed in the active military, naval, or air service for six months or more shall be taken to have been in sound condition when examined, accepted and enrolled for service except as to defects, infirmities, or disorders noted at the time of the examination, acceptance and enrollment, or where evidence or medical judgment is such to warrant a finding that the disease or injury existed before acceptance and enrollment. The appellant's history of a thyroidectomy on service entrance examination and the July 1986 report of use of medication for 5 years constitutes the necessary clear evidence needed to rebut the presumption of soundness as set forth above. See e.g. Wilson v. Brown, U.S. Vet. App. No. 91-1256 (Feb. 17, 1993). The Board must now determine whether or not the appellant's preexisting thyroid disorder increased in severity during service. A pre-existing injury or disease will be considered to have been aggravated by active military, naval, or air 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.A. § 1153 (West 1991). We note that in Hunt v. Derwinski, 1 Vet.App. 292 (1991) the United States Court of Veterans Appeals held that temporary or intermittent flare-ups during service of a pre-existing injury or disease are not sufficient to be considered "aggravation in service" unless the underlying condition, as contrasted to symptoms, is worsened. In weighing the evidence of record, the undersigned concludes that the preponderance of the evidence is against the appellant's claim to service connection for a thyroid disorder. The record establishes that the appellant, by her own reports, had a thyroidectomy in 1980 at the age of 18, prior to her period of service from June 1986 to March 1987. Although she has testified at her hearing in March 1994 that she was on medication for her thyroid disorder for only one year after the surgery, the record reflects that in July 1986 several months after service entry she requested that her Synthroid prescription by refilled and reported that she had been taking Synthroid for approximately five years. This report would appear consistent with the reported thyroid surgery sometime in 1980 and the need for a course of thyroid replacement medication from that time until service entry in 1986. While she has argued that the need for thyroid medication during service is representative of an increase in severity of her thyroid disorder, the Board believes that her request for thyroid medication refill shortly after service entry and the five year thyroid medication history reported at that time are inherently more probative than the testimony provided solely for the purposes of obtaining compensation benefits. When viewed in light of the lack of any additional evidence, either during service or after service discharge, to support a finding of an increase in severity of the preexisting thyroid disorder, the undersigned concludes that the weight of the evidence is against entitlement to service connection for a thyroid disorder based upon aggravation of the preexisting disorder. 38 U.S.C.A. § 1153 (1993). II. Hypertension Review of the record reveals that a hospitalization report covering the period from December 27, 1986 to January 4, 1987 noted diagnoses which included pregnancy induced hypertension. A subsequent treatment report dated in February 1987 noted an elevated blood pressure reading of 136/100; however, no additional information was provided. In December 1988 a private outpatient treatment report noted a blood pressure reading of 170/112. It was further noted that the appellant developed hypertension during each pregnancy with resolution after delivery until the last delivery in September 1988. Although the appellant testified that she was diagnosed with chronic hypertension during service, and the December 1986 to January 1987 hospitalization report included a diagnosis of pregnancy induced hypertension termed chronic hypertension, the Board notes that 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." The service medical records do not confirm the presence of chronic hypertension during the remainder of the appellant's period of active duty. There is no additional medical evidence of record to establish that the pregnancy induced hypertension during service was representative of anything other than the elevated findings associated with the pregnancy. It is significant to note that upon service entry in March 1986, the appellant's blood pressure was reported as 128/80. The first report of elevated blood pressure readings were noted during the later stages of her pregnancy. Continuity of symptomatology is required where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R.§ 3.303(b) (1993). In view of the above, the undersigned concludes that chronicity of hypertension in service has not been adequately supported and therefore review of the post service medical records is necessary to determine whether continuity of symptomatology is shown. The post service evidence of record is silent with regard to hypertension until August 1988 when a private hospitalization report noted a diagnosis of hypertension. However, the appellant was approximately eight months pregnant at that time. The next report of hypertension was during private outpatient examination in December 1988 which noted that the appellant had a history of hypertension with each pregnancy with resolution after delivery until the last delivery in September 1988. A diagnosis of essential hypertension was subsequently confirmed during private outpatient treatment in 1989 and on VA examination in December 1990. The appellant's contentions and testimony have been carefully considered, but are found to be outweighed by the objective evidence of record. The lack of evidence of chronicity during service coupled with the lack of continuity of symptomatology until approximately September 1988 weighs against the appellant's claim to service connection for hypertension. There is no medical evidence of record to establish that the elevated blood pressure readings during service and associated with the appellant's pregnancy were representative of the onset of chronic hypertension. III. Chronic Headaches The record reflects no complaints, findings or manifestations of a chronic headache disorder during the appellant's period of service. While a statement from a private psychologist dated in March 1994 noted that the appellant had been treated for probable concussive trauma of a severe nature and post traumatic headaches since June 1987, there was no information as to when the alleged trauma occurred and the service medical records reveal no evidence of the appellant having sustained "concussive" trauma during service. Moreover, there is no evidence of record to confirm that the appellant ever sustained "concussive" trauma. Private outpatient treatment reports dated from 1988 to 1990 note that the appellant was seen for headaches as well as other complaints. In November 1990, a diagnostic assessment of probable vascular headache was noted. The first objective report of "chronic" headaches was on VA examination in December 1990 during which a diagnosis of headaches, stress related and exacerbated by a refractive error was noted. On ophthalmologic examination the assessment included headaches which may be secondary to refractive error. There was no objective evidence to relate the appellant's headaches to her period of service. Although the appellant testified that she developed chronic headaches during service and that she had been told that the headaches may be due to her thyroid disorder and hypertension, the objective evidence of record does not support her testimony. Furthermore, since neither the thyroid disorder or hypertension are service-connected disabilities, any relationship among those disabilities and chronic headaches is considered to be irrelevant to the issue on appeal. In view of the above, the undersigned concludes that the weight of the evidence is against the appellant's claim to service connection for chronic headaches. In reaching this conclusion, particular emphasis has been placed upon the lack of pertinent objective findings to even suggest the presence of a chronic headache disorder during service. While headaches were noted after service discharge they were considered to be associated with stress and exacerbated by refractive error, and there simply is no objective basis within the record to relate those findings to the appellant's period of active duty. Accordingly, entitlement to service connection for chronic headaches is not warranted. IV. Residuals of a Cesarean Section Review of the record reveals that during service, the appellant underwent a repeat low transverse cesarean section procedure during the birth of her child in December 1986. Subsequent service medical records reflect no complaints, findings or manifestations of residuals related to that procedure. However, on VA examination in December 1990, a 14 cm. by 2 cm. cesarean section scar was noted and was described as tender in the distal portion with subjective complaints of crampy discomfort. The Board notes that the record reflects that the appellant underwent a cesarean section prior to service entry and again gave birth after service discharge in September 1988. In view of the lack of pertinent findings on service entrance examination in March 1986, residuals from the preservice cesarean section may reasonably be ruled out. Furthermore, there is no evidence to establish the presence of residuals of the cesarean section performed in December 1986 during service or from service discharge until December 1990, where the presence of a tender scar and complaints of crampy discomfort were noted on VA examination. The appellant's testimony and reported history on VA examination in December 1990 are found to be outweighed by the objective evidence of record which reflect no findings of residual disability associated with the December 1986 cesarean section either during service or any time thereafter including when the appellant gave birth in September 1988. The lack of findings of residuals during service at the time of the surgery or at any time thereafter coupled with the lack of findings until VA examination in December 1990, which time period encompasses the intervening birth in September 1988, is found to be sufficient to disassociate the findings reported in December 1990 from the cesarean section performed in December 1986. Accordingly, entitlement to service connection for residuals of a cesarean section is not warranted. V. Major Depression The service medical records reflect no complaints, findings or manifestations of a psychiatric disorder to include depression during service. While a private psychologist noted in March 1994 that the appellant was first seen for depression in June 1987, that treatment was approximately 3 months after service discharge and there was no evidence to relate that treatment to the appellants' period of service. A private outpatient treatment report dated in April 1989 noted that the appellant was seen for complaints of depression. However, again, there was no basis to relate those complaints to the appellant's period of active duty. While major depression, single episode was diagnosed on VA examination in December 1990, it was further noted that the appellant's mother had died suddenly in 1986 and that the depression seemed to be related to either her mother's death and/or the physical injury she had suffered. It is significant to note that the objective evidence of record does not confirm that the appellant sustained an injury during her period of active duty. Furthermore, the appellant testified at her hearing in March 1994 that she was first treated for depression in late 1987 or early 1988 and indicated that the depression was probably related to her mother' s death and all of her medical problems. In view of the above and the lack of evidence of a psychiatric disorder to include major depression during service or of a psychosis manifested to a compensable degree within the initial post service year, the undersigned concludes that the weight of the evidence is against the appellant's claim to service connection for depression. The objective evidence of record does not establish a basis upon which to relate the post service findings of major depression to the appellant's service. Accordingly, entitlement to service connection for major depression is not warranted. VI. Iron Deficiency Anemia Review of the record confirms the presence of iron deficiency anemia during service and after service discharge. However, iron deficiency anemia alone, is a symptom of an underlying disease entity and is not considered a disease or disability for which service connection may be granted in the absence of identification of the underlying disease entity. In this case, the evidence of record does not identify the underlying disease entity. Accordingly, entitlement to service connection for a disorder manifested by iron deficiency anemia is not warranted. Based on the foregoing, the Board believes that service connection for the claimed disabilities should be denied. The preponderance of the evidence found probative to these issues weighs against a grant of benefits sought; the benefit of the doubt is for application where there is an approximate balance of the evidence of record. 38 U.S.C.A. § 5107 (b) (West 1991). ORDER The appeal is denied. KENNETH R. ANDREWS, JR. Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. (CONTINUED ON NEXT PAGE) NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991), a decision of the Board of Veterans' Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans' Judicial Review Act, Pub. L. No. 100-687, § 402 (1988). The date which appears on the face of this decision constitutes the date of mailing and the copy of this decision which you have received is your notice of the action taken on your appeal by the Board of Veterans' Appeals.