BVA9505222 DOCKET NO. 93-08 912 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Seattle, Washington THE ISSUES 1. Entitlement to an increased evaluation for a hiatal hernia, post-operative, currently evaluated as 20 percent disabling. 2. Entitlement to an increased evaluation for hypertension, currently evaluated as 10 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Christine E. Puffer, Associate Counsel INTRODUCTION The veteran had active service from November 1974 to November 1985. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 1991 rating decision of the Department of Veterans Affairs (VA) Seattle, Washington, Regional Office (RO) which granted service connection for a hiatal hernia, post- operative, and for hypertension, evaluated as 20 and 10 percent disabling, respectively. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends, in essence, that his service-connected disabilities are more severely disabling than his current evaluations reflect. He has reported that he experiences severe cramping, lower quadrant pain, and continuous gas. The veteran has noted that after a recent examination his medications were increased, and that VA physicians have suggested that he contact his private physician regarding obtaining medication for hypertension because his blood pressure is erratic. It has been requested that the veteran be accorded the benefit of every reasonable doubt. 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 granting increased ratings for a hiatal hernia, post-operative, and for hypertension. FINDINGS OF FACT 1. All evidence necessary for an equitable adjudication of the instant claim has been obtained by the RO. 2. The residuals of the veteran's hiatal hernia, post-operative, are manifested by epigastric distress, diarrhea, and rare cramping which are productive of no greater than mild impairment. 3. Although the record contains several diastolic blood pressure readings of 100, the veteran has never manifested diastolic blood pressure readings of predominantly 110 or more. CONCLUSIONS OF LAW 1. The schedular criteria for an evaluation in excess of 20 percent for hiatal hernia, post-operative, have not been satisfied. 38 U.S.C.A. §§ 1155, 5107(a) (West 1991); 38 C.F.R. § 4.114, Diagnostic Codes 7305 and 7346 (1994). 2. The schedular criteria for an evaluation in excess of 10 percent for hypertension have not been satisfied. 38 U.S.C.A. §§ 1155, 5107(a) (West 1991); 38 C.F.R. § 4.104, Diagnostic Code 7101 (1994). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS As a preliminary matter, the Board finds that the veteran's claims are well-grounded within the meaning of 38 U.S.C.A. § 5107(a). See Murphy v. Derwinski, 1 Vet.App. 78, 81 (1990). That is, the Board finds that he has presented claims which are not implausible when his contentions and the evidence of record are viewed in the light most favorable to the claims. The Board is also satisfied that all relevant facts have been properly and sufficiently developed. The veteran maintains that his service-connected hiatal hernia, post-operative, and hypertension are more severely disabling than his current evaluations reflect. He has reported that he suffers from very bad cramps, lower quadrant pain and continuous gas. At a recent VA examination, he related experiencing bad headaches due to his high blood pressure. Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155. Separate diagnostic codes identify the various disabilities. The rating schedule recognizes that a veteran's disability evaluation may require reratings in accordance with changes in his physical condition. It is thus essential, in evaluating a disability, that it be viewed in relation to its history. 38 C.F.R. § 4.1. I. Background In support of his claim, the veteran submitted numerous medical records reflecting treatment from various medical facilities and his private physician from 1987 through 1991. The veteran received frequent and extensive treatment for neurological and orthopedic complaints throughout that time period. Although numerous entries reflecting such treatment are of record, very few of them relate in any manner to either of the conditions on appeal. Medical examinations as recently as 1991 indicated that the veteran was taking no medications other than those prescribed for orthopedic complaints. In August 1988, the veteran presented for emergency medical care after accidentally overdosing on medications in an effort to alleviate a headache. On examination, his bowel sounds were normal and his abdomen was soft and nontender. No gastrointestinal complaints were made. Blood pressure readings taken at the time included 178/97, 158/89 and 148/85. At the time of a January 1989 medical examination, the veteran offered no relevant complaints. No bladder or bowel dysfunction was observed, and gastrointestinal examination was essentially negative. The veteran's abdomen was soft without tenderness or palpable organomegaly. The veteran presented for emergency care in May 1990 due to severe stomach pain which he attributed to accidentally ingesting a toothpick. Examination revealed his bowel tone to be somewhat diminished, but present. There was generalized abdominal tenderness, but no guarding, rebound, masses or organomegaly. The impression was gastritis with small Mallory-Weiss tear. The examiner explained to the veteran that he had contracted some gastritis and had a small Mallory-Weiss tear, neither of which required further treatment. A report of a neurosurgical admission to Providence Hospital in February 1991, for an unrelated condition, noted that an examination had revealed the veteran's abdomen to be soft and without masses. His medical history was noted to be significant for no major medical problems, and a repair of a hiatal hernia in the 1970s was documented. Records from the Snohomish Clinic Medical Services Corporation document treatment of the veteran from February 1987 to May 1991 by his private physician, John A. Anderson, D.O. None of the doctor's entries reflect any complaints regarding headaches, high blood pressure, or gastrointestinal problems. The sole record relating to either issue on appeal is a May 1991 entry, wherein Dr. Anderson noted that the veteran had informed him of having stomach problems, of which the doctor indicated he was not previously aware, and reported that he took Tagamet. Blood pressure readings taken by Dr. Anderson included: February 1987, 150/95; May 1987, 150/90; and June 1988, 130/84. At the time of an August 1991 VA examination, the veteran recounted the clinical history of his gastrointestinal problems. He reported that he experienced a considerable amount of abdominal cramps in 1979 with marked regurgitation. An endoscopy had revealed a hiatal hernia and esophagitis. He underwent surgical correction, which rendered him unable to belch or vomit. The veteran reported that he currently experienced considerable bloating after meals with cramping abdominal pain and diarrhea, and usually had three to five stools a day. No significant bleeding was reported, and his symptoms were handled through the use of Tagamet or Rolaids. He further indicated that his symptoms had been relatively constant over the years, and that he had maintained his weight. With respect to his blood pressure, it was noted that it had been intermittently elevated since 1975, but had never necessitated medication. The veteran reported that his current physician also had not prescribed medication. On physical examination, the veteran presented as healthy, with three separate blood pressure readings of 160/100. Evaluation of his abdomen was negative, with no palpable masses, normal bowel tones, and no evidence of a hernia. The impressions were essential hypertension and post-operative situation of previous hiatal hernia repair. As it was questioned whether the veteran had some degree of post vagotomy syndrome, and upper gastric intestinal X-ray was requested. The test revealed evidence of erosive gastritis. The upper gastrointestinal examination report itself noted diagnoses of moderate erosive gastritis, moderate peptic duodenitis, and Nisson fundoplication without evidence for obstruction, with no evidence of reflux esophagitis. Citing the above-noted findings, the RO granted the veteran service connection by rating action of October 1991 for hiatal hernia, post-operative, evaluated as 20 percent disabling under 38 C.F.R. § 4.114, Diagnostic Codes 7346-7308; and for hypertension, evaluated as 10 percent disabling pursuant to 38 C.F.R. § 4.104, Diagnostic Code 7101. Although no diagnosis of hypertension had been rendered in service, the RO noted several elevated blood pressure readings in service, and granted service connection on that basis. A May 1992 outpatient treatment record from the Seattle VA Medical Center (VAMC) documented the veteran's complaints of "dumping," having diarrheal stools four times a day, 30 minutes after he ate. It was reported that these symptoms had been present since his hiatal hernia repair surgery in 1977. The veteran also complained of worsening heartburn, gas, rare episodes of cramping, and two episodes of blockage when food had to be removed from his stomach. He denied nausea, vomiting, jaundice, or epigastric pain. No hematemesis or melena were reported, however he experienced occasional bright red blood per his rectum and had hemorrhoids. An initial blood pressure reading of 186/108 was taken, and a repeat reading was 150/98. On examination, the veteran presented in no acute distress. An abdominal midline scar, normal bowel sounds, and a nontender abdomen were noted. No hepato-slenomegaly was evident, and he was rectal guaiac negative. The impression was status post hiatal hernia repair which appeared intact. The veteran's medication was increased, and another medication was added. He was scheduled for an esophagogastroduodenoscopy. At the time of a follow-up examination in July 1992, the veteran's blood pressure reading was 140/86. It was reported that a June 1992 esophagogastroduodenoscopy had revealed esophagitis and antritis. Biopsies were taken of a prominent duodenal fold and the antrum, with no diagnostic alteration noted in the former. The veteran reported that he experienced gastroesophageal reflux disease twice a day, and had experienced watery stool soon after eating ever since his surgery in 1977. On examination, the veteran presented in no acute distress. Bowel sounds were normal, and the veteran's abdomen was soft and nontender. The veteran reported that he had a normal gastric level. The impression was of gastroesophageal reflux disease and a history of dumping syndrome, status post surgery, with no significant change. A follow-up appointment was scheduled in six months. II. Analysis The veteran's hiatal hernia, post-operative, has been evaluated pursuant to 38 C.F.R. § 4.114, Diagnostic Codes 7346-7308, and assigned a 20 percent rating. The criteria for a 20 percent rating for mild postgastrectomy syndrome under Diagnostic Code 7308 include infrequent episodes of epigastric distress with characteristic mild circulatory symptoms or continuous mild manifestations. A 40 percent evaluation, reflective of moderate severity, requires episodes of epigastric disorders with characteristic mild circulatory symptoms after meals of less frequency than would occur with a severe disorder, but with diarrhea and weight loss. The criteria for a severe condition, warranting a 60 percent rating, include nausea, sweating, circulatory disturbance after meals, diarrhea, hypoglycemic symptoms, and weight loss with malnutrition and anemia. Although the veteran has reported experiencing very bad cramps, on recent examination he indicated that the episodes were rare. He has consistently reported experiencing watery stools shortly after eating, although no evidence of circulatory involvement has been noted. At an August 1991 VA examination, the veteran reported that he had maintained his weight, and there is no evidence that he has experienced any significant weight loss. Where, as here, there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. See 38 C.F.R. § 4.7. In view of the totality of the evidence, the Board concludes that the veteran's gastrointestinal symptomatology more closely approximates the criteria for his present evaluation under the noted diagnostic code. The Board would point out, however, the veteran may also be evaluated pursuant to Diagnostic Code 7346. To warrant an increased rating to 30 percent under that diagnostic code, the veteran would have to experience persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. For a 60 percent evaluation, the criteria requires symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia, or other symptom combinations productive of severe impairment of health. 38 C.F.R. § 4.115. As noted, the veteran has not experienced weight loss, hematemesis or melena following his hernia repair surgery. Furthermore, he has never reported experiencing dysphagia, pyrosis or substernal or arm or shoulder pain. Therefore, the veteran fails to satisfy the requisite criteria for an increased rating under this section, as well. The veteran's hypertension is evaluated pursuant to 38 C.F.R. § 4.104, Diagnostic Code 7101, and assigned a 10 percent rating. That evaluation requires diastolic blood pressure readings of predominantly 100 or more. The criteria for an increased rating to 20 percent is diastolic pressure of predominantly 110 or more with definite symptoms; for a 40 percent evaluation, diastolic pressure of predominantly 120 or more and moderately severe symptoms should be manifested; and for a rating of 60 percent, diastolic pressure of predominantly 130 or more and severe symptoms is necessary. Of all the blood pressure readings that are contained in the record on appeal, the highest single diastolic reading was of 108 in May 1992, with the next highest being three readings of 100 in August 1991. Given that the veteran has never manifested a diastolic reading of 110 on any occasion, he fails to satisfy the criteria for an increased rating to 20 percent, the next higher evaluation. The Board would also point out that although the veteran's report of experiencing headaches associated with high blood pressure is not supported by the evidence of record, compensation for pain is encompassed within his current evaluation. See 38 C.F.R. § 4.59. III. Conclusion In reaching its decision with respect to each issue on appeal, the Board has considered the complete history of the disabilities in question as well as the current clinical manifestations and the effect the disability may have on the earning capacity of the veteran. See 38 C.F.R. §§ 4.1, 4.2, 4.41. The nature of the original disabilities have been reviewed and the functional impairment which can be attributed to pain or weakness has been taken into account. See 38 C.F.R. § 4.40. The manifestations of the veteran's conditions are not so exceptional or unusual so as to warrant evaluations in excess of those assigned on an extra- schedular basis. For example, it has not been shown that either of the veteran's conditions has caused marked interference with employment or necessitated frequent periods of hospitalization. See 38 C.F.R. § 3.321(b)(1). Accordingly, there is no basis for an increased rating with respect to either condition. ORDER An increased rating for hiatal hernia, post-operative, is denied. An increased rating for hypertension is denied. JACQUELINE E. MONROE 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. 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.