Citation Nr: 1214305 Decision Date: 04/19/12 Archive Date: 04/27/12 DOCKET NO. 08-08 564 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUES 1. Entitlement to an increased rating for right knee degenerative joint disease (DJD), currently rated as 10 percent disabling. 2. Entitlement to an increased rating for left knee degenerative joint disease (DJD), currently rated as 10 percent disabling. 3. Entitlement to service connection for hypertension. 4. Entitlement to service connection for prostatitis. 5. Entitlement to service connection for a condition manifested by chest pain, to include costochondritis and a heart condition. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD A. Cryan, Counsel INTRODUCTION The Veteran served on active duty from January 1991 to March 1991 and from January 2004 to April 2006 with an additional twenty-eight years of inactive duty service in the Reserves. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2007 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Detroit, Michigan. The Veteran testified at a hearing before the Board in June 2009. The Board remanded the Veteran's claims for additional development in December 2009. Additional evidence in the form of a November 2010 statement from the Veteran's private physician was received from the Veteran without a written waiver of consideration by the agency of original jurisdiction (AOJ) in February 2011. The issues of entitlement to increased ratings for right and left knee DJD being remanded are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, D.C. FINDINGS OF FACT 1. The Veteran has hypertension which is as likely as not related to his active service. 2. There is no clear and unmistakable evidence that any prostate disability preexisted the Veteran's entry to service. 3. The Veteran has prostatitis which is as likely as not related to his active service. 4. The Veteran has coronary artery disease that is as likely as not related to active service. 5. The Veteran has chostochondritis that is as likely as not related to active service. CONCLUSIONS OF LAW 1. The Veteran has hypertension that was first manifested during active service. 38 U.S.C.A. §§ 1101, 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.306 (2011). 2. The Veteran has prostatitis that was first manifested during active service. 38 U.S.C.A. §§ 1101, 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.306 (2011). 3. The Veteran has coronary artery disease that is the result of disease incurred in active service. 38 U.S.C.A. §§ 1101, 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2011). 4. The Veteran has chostochondritis that was first manifested during active service. 38 U.S.C.A. §§ 1101, 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2011). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the United States Department of Veterans Affairs (VA) has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). In this decision, the Board grants service connection for hypertension, prostatitis, coronary artery disease, and costochondritis, and remands the other issues. Other than the matters addressed in the remand section, these awards represent a complete grant of the benefits sought on appeal. Thus, any deficiency in VA's compliance is deemed to be harmless error, and any further discussion of VA's responsibilities is not necessary. Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303 (2011). To establish service connection, there must be (1) medical evidence of a current disability, (2) medical evidence, or in certain circumstances lay testimony, of in-service incurrence or aggravation of an injury or disease, and (3) medical evidence of a nexus, or link, between the current disability and the in-service disease or injury. Pond v. West, 12 Vet. App. 341 (1999). In addition, certain chronic diseases, including hypertension and arteriosclerosis, may be presumed to have been incurred during service if the disorder becomes manifest to a compensable degree within one year of separation from active duty. 38 U.S.C.A. §§ 1101, 1112 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2011). Certain chronic disabilities, including cardiovascular-renal disease and hypertension, may be presumed to have been incurred in service if they become manifest to a degree of 10 percent or more within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. A Veteran who served in the active military, naval, or air service after December 31, 1946, is 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 clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C.A. § 1112 (West 2002). Only those conditions recorded in examination reports can be considered as noted and a history of preservice existence of conditions recorded at the time of examination does not constitute a notation of such conditions. 38 C.F.R. § 3.304(b) (2011). Determination of the existence of a pre-existing condition may be supported by contemporaneous evidence, or recorded history in the record, which provides a sufficient factual predicate to support a medical opinion or a later medical opinion based upon statements made by the Veteran about the pre-service history of his condition. Miller v. West, 11 Vet. App. 345 (1998); Harris v. West, 203 F.3d. 1347 (Fed. Cir. 2000). To rebut the presumption of sound condition for conditions not noted at entrance into service, VA must show by clear and unmistakable evidence both that the disease or injury existed prior to service and that the disease or injury was not aggravated by service. VAOPGCPREC 3-03 (July 16, 2003), 70 Fed. Reg. 23027 (May 4, 2005). A lack of aggravation may be shown by establishing that there was no increase in disability during service or that any increase in disability was due to the natural progress of the preexisting condition. Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004); 38 U.S.C.A. § 1153 (West 2002). Although the Veteran served during a period of war, he does not allege that any of the current disabilities at issue began in combat, and therefore the statue pertaining to proof of service incurrence or aggravation of a disease or injury in the case of a Veteran who engaged in combat with the enemy is not for application. 38 U.S.C.A. § 1154(b) (West 2002). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). In this regard, the Board must assess the credibility and probative value of evidence, and, provided that it offers an adequate statement of reasons or bases, the Board may favor one medical opinion over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995); Wood v. Derwinski, 1 Vet. App. 190 (1991). While the Board is not free to ignore the opinion of a treating physician, it is free to discount the credibility of that physician's statement. See Guerrieri v. Brown, 4 Vet. App. 467, 471-73 (1993); Sanden v. Derwinski, 2 Vet. App. 97, 101 (1992). Hypertension For VA purposes, the term hypertension means that the diastolic blood pressure is predominantly 90mm, or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160mm, or greater with a diastolic blood pressure of less than 90mm. 38 C.F.R. § 4.104, Diagnostic Code 7101, Note (1), under Diseases of the Arteries and Veins. These must be confirmed by readings taken two or more times on at least three different days. Id. As discussed below, because there is no competent evidence showing that the Veteran's hypertension was manifest to a degree of 10 percent or more during the first year following separation from service, service connection on a presumptive basis is not warranted in this case. See 38 U.S.C.A. §§ 1101 , 1112, 1137; 38 C.F.R. §§ 3.30 , 3.309. The Veteran's service treatment records reflect that the Veteran denied high or low blood pressure on report of medical history forms dated in June 1985, May 1989, July 1992, and May 1995. In March 1991, the Veteran's blood pressure was recorded as 151/91. However, he was noted to have injured his right knee at that time and no diagnosis of hypertension was proffered. An August 1991 VA examination did not include any complaints or findings related to hypertension. The Veteran's blood pressure was recorded as 130/83 and 127/77. The Veteran reported high or low blood pressure on a report of medical history form prepared in conjunction with an examination in March 2000. The March 2000 examination report shows that the Veteran was taking antihypertensive medication and that hypertension was controlled. A February 2004 annual medical certificate reveals that the Veteran was taking Cozaar, Atenolol, and HCTZ to treat his hypertension. An examiner noted that the Veteran's hypertension was controlled with his medications. An entry dated in January 2005 reflects that the Veteran was seen for a blood pressure check. His blood pressure was reported to be controlled with his current regimen of Atenolol, Cozaar, and HCTZ. In October 2005, the Veteran was seen for a blood pressure check and he was noted to be non-compliant with his medications and his blood pressure was noted to be under suboptimal control. In January 2006, the Veteran was seen for a blood pressure check. His blood pressure was noted to be 160/100. The examiner indicated that the Veteran was asymptomatic and the Veteran reported that he believed his blood pressure was elevated secondary to anxiety and knee pain. The examiner indicated that the Veteran's Atenolol dose was doubled and he was also taking HCTZ. Cozaar was noted to have been used in the past. In March 2006, the Veteran's blood pressure was reported to be 165/88 and he was noted to be asymptomatic. At a December 2006 VA examination, the Veteran reported taking anti-hypertensive medication for the previous ten years. The examiner noted that the Veteran had especially high blood pressure readings in service in October 2005. The Veteran indicated that his blood pressure was under fairly good control with medication and he denied any hypertensive crises. Physical examination revealed that the Veteran's blood pressure was reported to be 160/114 and 160/110 on two repeat readings. The examiner diagnosed the Veteran with hypertension, not well controlled. The examiner opined that the Veteran's condition was likely present during his military service. At a June 2009 hearing before the Board, the Veteran testified that his hypertension was diagnosed at least ten years prior to the hearing. However, he also stated that he first started taking medication for hypertension during his first period of service in 1991, and that his condition was aggravated during his second period of service due to exposure to heat and exercise during service. At a January 2010 VA examination, the Veteran reported a history of hypertension since 1996. The examiner reviewed the Veteran's claims file and noted the relevant medical history with regard to the Veteran's hypertension. The Veteran indicated that his hypertension was not well controlled with medication but he denied any hypertensive crises or frequent hospitalizations for control of hypertension. Physical examination revealed that the Veteran's blood pressure was reported to be 160/100, 160/98, and 160/96. The examiner diagnosed the Veteran with hypertension on medication not well controlled. The examiner noted that the Veteran's hypertension started in 1996 and was not aggravated during active service but was a normal natural progression of the course of his disorder during service. The Board notes that, in adjudicating a claim, it is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, the United States Court of Appeals for Veterans Claims (Court) has declared that, in adjudicating a claim, the Board has the responsibility to do so. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). Based on the foregoing, the Board finds that the evidence supports a finding that the Veteran's hypertension first manifested during his first period of service. In making this determination, the Board notes that the Veteran is competent to report that he was prescribed hypertension medication during his first period of service in 1991. See Washington v. Nicholson, 19 Vet. App. 362 (2005) (holding that a Veteran is competent to report what occurred during service because he is competent to testify as to factual matters of which he has first-hand knowledge). In this regard, the Board highlights that competent testimony is limited to that which the witness has actually observed and is within the realm of his personal knowledge; such knowledge comes to a witness through use of his senses-that which is heard, felt, seen, smelled or tasted. Layno v. Brown, 6 Vet. App. 465 (1994). It is within the Veteran's realm of personal knowledge whether he was given medication to control his hypertension during his first tour of duty in 1991. Moreover, the Board finds the Veteran's reports of being prescribed hypertension medication to be credible. His records are internally consistent, and it is facially plausible that he was diagnosed as having hypertension and given prescription medication, as he was found to have a blood pressure reading in March 1991 that was in the range for hypertension. While the Veteran has made inconsistent statements regarding when his hypertension was first diagnosed, this is not enough to find his statements uncredible. He is competent to report that he was first given prescription medication in March 1991 but as a lay person he is not competent to diagnose himself with hypertension as of 1996. As such, the Board finds that the Veteran's statements with respect to his being prescribed hypertension medication in service are credible and probative, and add weight to the overall claim. See Struck v. Brown, 9 Vet. App. 145, 155-156 (1996). The Board also finds it significant that a VA examiner in December 2006 noted the Veteran's period of service in 1991 and found that the Veteran's hypertension was likely present during his military service. Even though it appears that the examiner was relating the Veteran's hypertension to his second period of service, overall the opinion is favorable to the Veteran's claim. While a January 2010 VA examiner did not provide a favorable opinion, the VA examiner did not offer any rationale for the opinion that the Veteran's hypertension was not aggravated by his military service. This is significant because the Veteran has stated that his hypertension was aggravated during his service due to exposure to heat and exercise during his second tour in Desert Storm. He also testified that he first started taking hypertension medication during his first period of service in Desert Storm, including Cozar and Hydrochlorothiazide, and has argued that his hypertension first manifested during this service. A March 1991 medical entry also shows a blood pressure reading within the hypertension range for VA purposes, although no diagnosis was made at that time. The examiner did not consider any of this information in the opinion or offer any rationale for why no aggravation was found. A medical opinion based on speculation, without supporting clinical data or other rationale does not provide the required degree of medical certainty. Bloom v. West, 12 Vet. App. 185, 187 (1999); see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (a medical opinion "must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). After a careful review of the all of the medical and lay evidence of record, the Board, in its role as a finder of fact, finds that the Veteran's reports of being prescribed hypertension medication and the opinion from the December 2006 VA examiner are persuasive in determining the onset and etiology of his hypertension. While the January 2010 examiner's opinion weighs against the Veteran's claim it is not a persuasive opinion for the reasons stated above. Accordingly, applying the benefit of the doubt doctrine, all doubt is resolved in favor of the Veteran. See 38 C.F.R. § 3.102. Therefore, the Veteran's claim for service connection for hypertension is granted. Prostatitis The Veteran's service treatment records reflect that the Veteran denied frequent or painful urination on report of medical history forms prepared in June 1985, May 1989, February 1991, July 1992, May 1995, and March 2000. Clinical evaluations of the genitourinary system performed in June 1985, May 1989, February 1991, May 1995, and March 2000 were normal. In December 2004, the Veteran was treated for prostatitis with Cipro. In January 2005, the Veteran was treated for benign prostatic hypertrophy (BPH) controlled with Flomax. An August 1991 VA examination did not include any findings related to the Veteran's prostate. A urinalysis was normal with the exception of elevated urine mucus. Private treatment reports from J. Frontera, M.D., and B. Guz, M.D., of the Michigan Institute of Urology dated from November 2005 to November 2009 reflect that the Veteran was treated for prostatitis, bladder outlet obstruction, nonspecific voiding difficulties, borderline elevated prostate specific antigen (PSA), an enlarged benign prostate, erectile dysfunction, split urine stream, hematuria, and hypogonadism. The Veteran was noted to have a questionable history of prostatitis. A voided urine cytology dated in November 2005 was negative for malignancy but degenerative urothelial cell changes were noted. VA outpatient treatment reports dated from April 2006 to August 2006 reflect a medical history of benign prostatic hyperplasia and treatment with Flomax. The Veteran was afforded at VA general medical examination in December 2006. The Veteran reported a history of prostatitis and an enlarged prostate since 1996. Following a physical examination which noted that the Veteran's prostate was moderately enlarged, the examiner diagnosed the Veteran with benign enlarged prostate on medication. The examiner indicated that the Veteran reported a history of recurrent prostatitis, at present asymptomatic. The examiner stated that a PSA test was within normal limits. The examiner concluded that the Veteran's medical condition was likely present during service. At a June 2009 hearing before the Board, the Veteran testified that he had problems with urination and was later diagnosed with an enlarged prostate. The Veteran's representative indicated that the Veteran's prostate problem was directly related to his first period of service or in the alternative aggravated by his second period of service. At a January 2010 VA examination, the Veteran reported prostate enlargement and prostatitis since 1996. The examiner noted the Veteran's relevant medical history and the Veteran reported urinary symptoms related to prostate enlargement including frequency, hesitancy, and weak flow. The examiner indicated that the Veteran was treated for prostatitis in service and he was treated for his last episode of prostatitis five days prior to the examination. The Veteran indicated that since 2003, the frequency of prostatitis occurrences is two to three times per year and the frequency was the same during active service from 2004 to 2006. The examiner diagnosed the Veteran with benign prostate hypertrophy and recurrent prostatitis since 1996. The examiner found the Veteran had similar frequency of prostatitis during active service between 2004 and 2006 and there was no aggravation per the service records. As an initial matter, the Board finds that the Veteran's prostatitis was not noted at the time of the Veteran's examination, acceptance, and enrollment into service. In this case, the Veteran's entrance examination for his second period of service beginning in 2004 is not of record. Moreover, in this case there is no medical evidence dated prior to the Veteran's entrance into his second period of service which indicates that a diagnosis of prostatitis was rendered prior to the Veteran's entry into service in 2004. While the Veteran has stated that he had prostatitis symptoms since 1996, he is not competent to render such a diagnosis. Moreover, the January 2010 examiner's assessment that the prostatitis first manifested in 1996 is based solely on the Veteran's report and not on any medical evidence. Therefore, there is no clear and unmistakable evidence of a pre-existing prostate condition. Because the Veteran's prostatitis was not noted at the time of his examination, acceptance, and enrollment into service, and there is no clear and unmistakable evidence of a pre-existing condition, the Board finds that he is entitled to the presumption of soundness. With regard to the issue of entitlement to prostatitis on a direct basis, the Board finds that service connection is warranted. The record shows that the Veteran was treated for prostatitis in December 2004 during his active military service. Following service, the Veteran has also been treated for the same. The December 2006 VA examiner opined that the Veteran's prostatitis was likely present during his military service. While the January 2010 VA examiner diagnosed the Veteran with prostatitis since 1996 and indicated that there was no aggravation per the service records, the Veteran is presumed sound and the Board finds that there is not clear and unmistakable evidence of record to rebut the presumption of soundness. Therefore, the Board finds that the Veteran's prostatitis did not pre-exist service. The Veteran was treated for prostatitis during active service and he has been treated for the same since service. Because the Veteran was presumed sound, and then treated for prostatitis during his active service, the Board will resolve reasonable doubt in favor of the Veteran and find that prostatitis was incurred in service. Accordingly, the Board resolves reasonable doubt in favor of the Veteran and finds that he was presumed sound upon entry to service and was treated for prostatitis during service and after service. Therefore, the Board finds that prostatitis was incurred in service and that service connection for prostatitis is warranted. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Heart Disability/ Chostochondritis The Veteran's service treatment records reflect that he reported left-sided chest pain in April 2004. An echocardiogram (EKG) revealed normal sinus rhythm, left ventricular hypertrophy, and possible left atrial enlargement. The Veteran was assessed with costochondritis. The Veteran was referred for a consultation for atypical chest pain in January 2006. The results of any cardiac testing from January 2006 were not associated with the claims file. A March 2006 entry notes that the cardiology notes were reviewed and the Veteran was to be returned to duty. Private treatment reports from St. Joseph's Healthcare reflect that the Veteran was seen for a report of chest pain in December 2006. VA treatment records dated from April to August 2006 do not reflect any cardiac diagnoses. At a December 2006 VA examination, the Veteran reported left second costosternal area pain off and on for the previous ten years. The Veteran indicated that his last episode of chest pain was in March 2006. Following a physical examination, the examiner diagnosed the Veteran with recurrent costochondritis by history, presently asymptomatic. The examiner concluded that the Veteran's condition was likely present during military service. Private treatment reports from Henry Ford Macomb Hospital reflect that the Veteran was seen for reports of chest pain in January 2008. Private treatment reports from Eastside Cardiovascular Medicine reflect reports of atypical left chest pain at times constant in nature in January 2008. The Veteran was assessed with arteriosclerotic heart disease (ASHD), status post cardiac catheterization. Additional records dated through March 2010 reflect the same diagnosis. At a June 2009 hearing before the Board, the Veteran testified that while he was diagnosed with a muscle injury related to his reports of chest pain in service, following service he underwent a cardiac catheterization and was diagnosed with a 50 percent blockage in one of the arteries on the left side of his heart. He testified that he has not undergone a stent placement because stents are placed for blockages greater than 50 percent. At a January 2010 VA examination, the Veteran reported intermittent chest pain since 1996. The Veteran indicated that he has chest pain four to six times per year usually related to moderate to strenuous activity. The examiner noted that the Veteran stated he had been diagnosed with a heart condition in 2007 by his private cardiologist. A heart catheterization performed in 2007 was noted to reveal a 50 percent blockage of one of the Veteran's heart vessels. The examiner indicated that the Veteran takes medications but has not undergone an angioplasty, stent placement, or heart surgeries. The examiner noted that the Veteran's VA treatment records indicate that he has a diagnosis of coronary artery disease as of June 2009. Following a physical examination, the examiner diagnosed the Veteran with atypical chest pain, most likely costochondritis by history since 1996 with the same frequency during service and coronary artery disease diagnosed in 2007 per current history. The examiner indicated that there was no documentation of coronary artery disease during active service from 2004 to 2006 and that it was not likely related to service. The Board notes that, in adjudicating a claim, it is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, the United States Court of Appeals for Veterans Claims (Court) has declared that, in adjudicating a claim, the Board has the responsibility to do so. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). Based on the foregoing, the Board finds that the evidence supports a finding that the Veteran's coronary artery disease and costochondritis first manifested during his military service. In making this determination, the Board notes that the Veteran is competent to report that he experienced chest pain in service and continued to experience chest pain after service. See Washington v. Nicholson, 19 Vet. App. 362 (2005) (holding that a veteran is competent to report what occurred during service because he is competent to testify as to factual matters of which he has first-hand knowledge); Barr v. Nicholson, 21 Vet. App. 303, 307-08 (2007) (holding that lay testimony is competent to establish the presence of observable symptomatology); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Competent testimony is limited to that which the witness has actually observed and is within the realm of his personal knowledge. Such knowledge comes to a witness through use of his senses-that which is heard, felt, seen, smelled or tasted. Layno v. Brown, 6 Vet. App. 465 (1994). Moreover, the Board finds the Veteran's reports of having chest pain since service and undergoing a cardiac catheterization in 2007 to be credible. His records are internally consistent, and it is shown that he complained of chest pain in service and after service. It also is facially plausible that he underwent a cardiac catheterization in 2007, as he was diagnosed as having coronary artery disease in January 2008. As such, the Board finds that the Veteran's statements with respect to his continued symptomatology since service are credible and probative, and add weight to the overall claim. See Struck v. Brown, 9 Vet. App. 145, 155-156 (1996). The Board also finds it significant that the cardiac catheterization performed in 2007 is close to, if not within, the presumptive one-year period from the Veteran's discharge from the military. See 38 C.F.R. § 3.309(a). While a January 2010 VA examiner did not provide a favorable opinion, the VA examiner did not offer any rationale for the opinion that the Veteran's coronary artery disease was not related to military service, other than to note that it was not diagnosed in service, which is not fatal to the Veteran's claim. After a careful review of the all of the medical and lay evidence of record, the Board, in its role as a finder of fact, finds that the Veteran's reports of chest pain in service and after service, his report of a cardiac catheterization in 2007, and current diagnosis of coronary artery disease since January 2008 are persuasive in determining the onset and etiology of his coronary artery disease. While the January 2010 examiner's opinion weighs against the Veteran's claim it is not a persuasive opinion for the reasons stated above. Regarding the costochondritis, although the January 2010 VA examiner found that the Veteran's costochondritis first manifested in 1996, this was solely based on the Veteran's reports that he first noticed chest pain in 1996, and not on any medical evidence. The service treatment records actually show that this condition was first diagnosed in March 2004. A December 2006 VA examiner also found that costochondritis was likely related to the Veteran's military service. As noted above, when, after consideration of all evidence and material of record in a case, there is an approximate balance of positive and negative evidence regarding any material issue, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b) ; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990) (holding that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail."). Because there is medical evidence in 2007, close to, if not within one year of the Veteran's military discharge, that led to a diagnosis of a coronary artery disease in 2008, and credible supporting evidence of continued complaints of chest pain since service, as well as a diagnosis of costochondritis in service, and a medical opinion relating the Veteran's costochondritis to service, the Board concludes that the evidence supports the grant of service connection for coronary artery disease and costochondritis. Thus, following a full review of the record, and applying the benefit of the doubt doctrine, all doubt is resolved in favor of the Veteran. See 38 C.F.R. § 3.102. Therefore, the Veteran's claim for service connection for coronary artery disease and costochondritis is granted. ORDER Entitlement to service connection for hypertension is granted. Entitlement to service connection for prostatitis is granted. Entitlement to service connection for coronary artery disease is granted. Entitlement to service connection for costochondritis is granted. REMAND A review of the claims file reveals that a remand is necessary before a decision on the merits of the claims for increased rating for DJD of the right and left knee can be reached. Following issuance of a January 2011 supplemental statement of the case, the Veteran submitted a November 2010 letter from his treating orthopedic physician. The Veteran did not indicate that he waived review of consideration by the AOJ for the newly submitted evidence. The letter, from K. Scott, D.O., indicates that the Veteran had been Dr. Scott's patient for six years and has had multiple knee effusions and swelling as well as procedures to drain the knee along with physical therapy. The previous examination in January 2010 notes that the Veteran had no effusions or swelling of the knees. In light of the fact that the November 2010 letter was submitted without a waiver of AOJ consideration and because the letter suggests that the Veteran's knee may have worsened since the last VA examination in January 2010, another examination should be scheduled to determine the current nature and severity of the service-connected DJD of the bilateral knees. VA outpatient treatment records dated through August 2006 have been associated with the claims file. Because there may be outstanding VA medical records that contain information pertinent to the Veteran's claims, an attempt to obtain any VA records dated after August 2006 should be made. 38 C.F.R. § 3.159(c)(2) (2011); Bell v. Derwinski, 2 Vet. App. 611 (1992). Accordingly, the case is REMANDED for the following action: 1. Obtain any VA outpatient treatment records for the period from August 2006 to the present, which have not already been associated with the claims file. Any other pertinent records identified by the Veteran should also be requested and associated with the claims file, if available. 2. Schedule the Veteran for A VA orthopedic examination to determine the extent of his right and left knee disabilities. All necessary tests and studies, including range of motion studies, should be conducted. The examiner should specifically indicate whether the Veteran's knee disabilities are manifested by lateral instability or recurrent subluxation and whether such instability or subluxation is slight, moderate, or severe. The report should discuss any weakened movement, excess fatigability with use, incoordination, painful motion, or pain with use, and provide an opinion as to how those factors result in any additional limitation of function. If the Veteran describes flare-ups of pain, the examiner should offer an opinion as to whether there are additional limits on functional ability during flare-ups. All losses of function due to problems such as pain should be equated to additional degrees of limitation of flexion and extension beyond that shown clinically. 3. Then, readjudicate the issues on appeal. If any decision is adverse to the Veteran, issue a supplemental statement of the case and allow the applicable time for response. Then, return the case to the Board. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2011). ______________________________________________ SARAH B. RICHMOND Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs