BVA9504010 DOCKET NO. 91-49 583 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Entitlement to service connection for hypertension. 2. Entitlement to service connection for residuals of a low back injury. 3. Entitlement to service connection for residuals of a head injury, including headaches and facial trauma. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant; S.T. ATTORNEY FOR THE BOARD M. J. Bohanan, Associate Counsel INTRODUCTION The appellant served on active duty from November 1953 to November 1955. This appeal arises from a September 1989 Department of Veterans Affairs, St. Louis, Missouri (VARO) rating decision, which denied the appellant service connection for hypertension, residuals of a low back injury and residuals of a head injury. CONTENTIONS OF APPELLANT ON APPEAL The appellant contends, in substance, that he currently suffers from a low back disorder and the residuals of a head injury, including headaches and facial trauma, which did not exist at the time of his service entrance and were acquired as the result of an automobile accident during service. He further claims that he developed hypertension during his 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 service connection for hypertension, the residuals of a low back injury and the residuals of a head injury, including headaches and facial asymmetry, is warranted. FINDINGS OF FACT 1. The appellant served on active duty from November 1953 to November 1955. 2. Objective medical evidence substantiates that the appellant developed hypertension during service. 3. The appellant injured his back and head when he was involved in an automobile accident during service. 4. Objective medical evidence substantiates that the appellant currently suffers from a low back disability and headaches; mild facial asymmetry has been noted. CONCLUSIONS OF LAW 1. The appellant suffers from hypertension that is presumed to have been incurred in service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113 (West 1991); 38 C.F.R. §§ 3.303(b), 3.307, 3.309 (1993). 2. The appellant suffers from the residuals of a low back injury which were incurred in military service. 38 U.S.C.A. §§ 1101, 1110 (West 1991); 38 C.F.R. § 3.303(b) (1993). 3. The appellant suffers from the residuals of a head injury, including headaches and facial asymmetry, that were incurred in military service. 38 U.S.C.A. §§ 1101, 1110 (West 1991); 38 C.F.R. § 3.303(b) (1993). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS This section of the Board, in reaching its decision in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991), has reviewed and considered all relevant evidence and material of record incorporated in the appellant's claims folder and its attachments. The appellant is seeking service connection for hypertension, the residuals of a low back injury, and the residuals of a head injury, including headaches and facial trauma. Under pertinent law and VA regulations, service connection may be granted if symptomatology attributable hypertension, the residuals of a back injury or the residuals of a head injury appeared during service; or, with regard to hypertension, within one year thereafter. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113 (West 1991); 38 C.F.R. §§ 3.307, 3.309 (1993). It is not necessary to have a diagnosis of a particular disorder during service, but it is necessary to have manifestations sufficient to establish that the disorder was present. 38 C.F.R. § 3.303(d) (1993). Initially, the Board finds that the appellant has submitted evidence which is sufficient to justify a belief that his claim is well grounded. 38 U.S.C.A. § 5107(a) (West 1991) and Murphy v. Derwinski, 1 Vet.App. 78 (1990). Furthermore, the Board believes that this case has been adequately developed for appellate purposes by VARO and that it may therefore proceed to a disposition on the merits without the necessity of a remand for further records. For the sake of clarity, after a review of the appellant's pertinent medical history, the Board will separately discuss each of the issues presented in this appeal. Medical history The appellant's complete service medical records are unavailable. However, an April 1954 military treatment report reveals that the appellant was hospitalized after he received a traumatic hematoma on his right cheek during an automobile accident. The appellant received aspiration of the hematoma and was discharged to duty. A September 1954 military medical profile reported that the appellant was treated for "back trouble", described as "permanent." The examiner recommended limitations of physical activity. Copies of photographs taken in 1954 are of record, which indicate that the appellant's right cheek was very enlarged and swollen. A statement from the appellant's private physician, Revis C. Lewis, M.D., reported that the appellant was treated for disc removal at L4-L5, left, in December 1975. Dr. Lewis reported that the appellant claimed a history of hypertension during his first office visit and had a blood pressure reading of 160/90. An acquaintance of the appellant's, C.C., submitted an October 1989 statement and claimed that the appellant had hypertension "since his hospitalization in 1954." A May 1989 statement from the appellant's private physician, John Balhuizen, M.D., P.C., was submitted. Dr. Balhuizen reported that he had been treating the appellant for hypertension. The appellant's private physician, James A. DiRenna, Jr., D.O., also submitted a May 1989 statement. Dr. DiRenna reported that the appellant had been receiving treatment at the DiRenna Clinic, Inc. from the "1950's thru approximately February of 1968." However, no medical treatment records were available. In an October 1989 statement, Dr. DiRenna, Jr. reported that Dr. DiRenna, Sr. recalled treating the appellant for hypertension from 1955 to 1968. At his July 1991 hearing on appeal, the appellant testified that he was advised to seek treatment for hypertension at the time of his military separation examination. He claimed that he received treatment from Dr. DiRenna, Sr. from 1955 to 1968, and that he then began to receive treatment from Dr. Bulhuizen. The appellant's wife, S.T., confirmed that the appellant was treated for hypertension following service. The appellant also testified that, as a result of an automobile accident in April 1954, he hit the right side of his cheek on the passenger door. He claimed that he had headaches, swelling and pain due to his cheek injury, and received "neck traction." He also claimed that his back was injured during the accident and that he had pain when he sat down or got up. He testified that he received treatment from chiropractors after service and eventually received treatment from a surgeon, Dr. Lewis. A VA examination was conducted in March 1994. The appellant complained of headaches once or twice a week and low back pain since his automobile accident in April 1954. A neurological examination revealed no evidence of tumor or malignancy, but did reveal evidence of an L5-S1 radiculopathy. Mild facial asymmetry was noted. The examiner diagnosed "post traumatic" tension headaches and L5-S1 radiculopathy of the left side. He opined that the appellant's headaches and back disorder were possibly related to his motor vehicle accident during service. Analysis 1. Entitlement to service connection for hypertension. After applying benefit of the doubt, the Board finds that the objective medical evidence substantiates that the appellant acquired hypertension during service. Although the complete service medical treatment records are unavailable, the Board places emphasis upon the statements of the appellant's private physician, Dr. DiRenna, Jr., which report that the appellant received treatment for hypertension from 1955 to 1968; and the statements of the appellant, his wife, S.T., and his acquaintance, C.C., which corroborated treatment for hypertension since service. The appellant was separated in November 1955; any treatment for hypertension as reported would fall within the one-year presumptive period. Further, the requirement of treatment for hypertension suggests the need for medication, and would support a 10 percent level of disability at that time. Therefore, it is the opinion of the Board that service connection for hypertension is warranted. 2. Entitlement to service connection for residuals of a low back disorder. The Board finds that the objective medical evidence substantiates that the appellant incurred the residuals of a low back injury during service, for which he had a disc removal at L4-L5 in December 1975. After again applying the benefit of the doubt, the Board finds that the appellant's low back disorder was incurred during service. In so finding, the Board places emphasis on the appellant's military physical profile which describes "permanent" back trouble; his medical treatment records subsequent to service which indicate that he continued to receive treatment for a back disorder after discharge; and his most recent March 1994 VA examination which reported that his current back disorder is possibly related to his motor vehicle accident during service. Therefore, it is the opinion of the Board that the appellant suffers from the residuals of a back injury during service and that entitlement to service connection for the residuals of a low back injury is warranted. 3. Entitlement to service connection for residuals of a head injury, including headaches and facial trauma. After again applying benefit of the doubt, the Board finds that the objective medical evidence substantiates that the appellant's residuals of a head injury, including headaches and facial trauma, were incurred during military service. The Board places emphasis on the appellant's service medical records, which reported that he received a hematoma requiring aspiration as the result of a motor vehicle accident in April 1954; and his most recent March 1994 VA examination which described the appellant's headaches as "post traumatic" and indicated that they could be related to his automobile accident in service. In addition, mild facial asymmetry was identified. Therefore, it is the opinion of the Board that the appellant's residuals of a head injury, including headaches and facial asymmetry, is warranted. ORDER Service connection for hypertension is granted. Service connection for residuals of a low back injury is granted. Service connection for residuals of a head injury, including headaches and facial asymmetry is granted. 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. 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.