Citation Nr: 1313355 Decision Date: 04/22/13 Archive Date: 05/03/13 DOCKET NO. 07-23 664 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUES 1. Entitlement to service connection for hypertension, including as due to a service-connected anxiety disorder. 2. Entitlement to service connection for residuals of a stroke, including as due to a service-connected anxiety disorder. REPRESENTATION Appellant represented by: Illinois Department of Veterans Affairs ATTORNEY FOR THE BOARD Jennifer Hwa, Counsel INTRODUCTION The Veteran served on active duty from August 1966 to July 1969. He also had service in the Illinois Army National Guard from January 1983 to January 1991 and from July 1991 to March 1999. This matter is before the Board of Veterans' Appeals (Board) on appeal from a December 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Chicago, Illinois, that denied the Veteran's claims for service connection for posttraumatic stress disorder (PTSD), hypertension, and residuals of a stroke. The Veteran was scheduled for a travel board hearing in May 2009. However, the Veteran failed to appear at this hearing. As the record does not contain any additional requests for a hearing, the Board deems the Veteran's request for a hearing to be withdrawn. See 38 C.F.R. § 20.702 (2012). In an August 2009 decision, the Board denied the Veteran's claim for service connection for PTSD and remanded his other claims for additional development. In September 2011, the Board again remanded the Veteran's claims for further development. The Board notes that, in addition to the paper claims file, there is a paperless, electronic (Virtual VA) claims file associated with the Veteran's claims. A review of the documents in such file reveals that they are either duplicative of the evidence in the paper claims file or are irrelevant to the issues on appeal. FINDINGS OF FACT 1. Chronic hypertension was not shown in service or within one year after discharge from service, and the most probative evidence fails to link the Veteran's current hypertension to service or to a service-connected disability. 2. Chronic residuals of a stroke were not shown in service or within one year after discharge from service, and the most probative evidence fails to link the Veteran's current residuals of a stroke to service or to a service-connected disability. CONCLUSIONS OF LAW 1. The requirements for establishing service connection for hypertension have not been met. 38 U.S.C.A. §§ 1110, 1112, 1131, 1137, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2012). 2. The requirements for establishing service connection for residuals of a stroke have not been met. 38 U.S.C.A. §§ 1110, 1112, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2012)) redefined VA's duty to assist a claimant in the development of a claim. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2012). The notice requirements of the VCAA require VA to notify the claimant of any evidence that is necessary to substantiate the claim, as well as the evidence VA will attempt to obtain and which evidence he is responsible for providing. 38 C.F.R. § 3.159(b) (2012). The requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between a veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO). Id.; see also Pelegrini v. Principi, 18 Vet. App. 112 (2004). However, the VCAA notice requirements may be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. See Pelegrini, 18 Vet. App. at 121. In this case, in January 2006 and September 2006 letters issued prior to the decision on appeal, the Veteran was provided notice regarding what information and evidence is needed to substantiate his claims for service connection, as well as what information and evidence must be submitted by the Veteran and what information and evidence will be obtained by VA. Letters dated in March 2006 and September 2006 also advised the Veteran of how disability evaluations and effective dates are assigned, and the type of evidence which impacts those determinations. In a July 2007 statement of the case, the Veteran was provided notice regarding what information and evidence is needed to substantiate his claim for service connection on a secondary basis. The case was last readjudicated in August 2012. Although the July 2007 notification regarding secondary service connection was issued after the adjudication on appeal, the Veteran's case was subsequently readjudicated in the July 2007 statement of the case and the February 2009, December 2010, May 2011, and August 2012 supplemental statements of the case. The Veteran also had the opportunity to submit additional argument and evidence. Therefore, the content timing error did not affect the essential fairness of the adjudication of the claims. Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007) (timing error cured by adequate VCAA notice and subsequent readjudication without resorting to prejudicial error analysis.). The record also reflects that VA has made reasonable efforts to obtain relevant records adequately identified by the Veteran. Specifically, the information and evidence that have been associated with the claims file include the Veteran's service treatment records, service personnel records, VA examination reports, private treatment records, pay statements for his National Guard service, and lay statements. Additionally, the prior remand instructions were substantially complied with. Instructions pertinent to the claims being decided included verification of the Veteran's active duty for training (ACDUTRA) and inactive duty for training (INACDUTRA) dates, obtaining pay statements for the Veteran's periods of ACDUTRA and INACDUTRA, and obtaining VA examinations and opinions regarding direct and secondary service connection theories of entitlement as well as opinions regarding aggravation of a congenital disability and disability due to herbicide exposure. In response, the RO/AMC obtained verification of the Veteran's ACDUTRA/INACDUTRA as well as pay statements for a period of ACDUTRA/INACDUTRA. Additionally, the RO/AMC scheduled the Veteran for VA examinations dated in March 2010, December 2010, October 2011, and December 2011 and obtained VA addendum opinions dated in May 2010, February 2011, March 2011, and December 2011. Accordingly, the Board finds that there has been substantial compliance with the prior remand instructions and no further action is necessary. See D'Aries v. Peake, 22 Vet. App. 97 (2008) (holding that only substantial, and not strict, compliance with the terms of a Board remand is required pursuant to Stegall v. West, 11 Vet. App. 268 (1998)). As discussed above, the VCAA provisions have been considered and complied with. The Veteran was notified and aware of the evidence needed to substantiate his claims, the avenues through which he might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. The Veteran was an active participant in the claims process by providing evidence and argument. Thus, he was provided with a meaningful opportunity to participate in the claims process and has done so. Any error in the sequence of events or content of the notices is not shown to have any effect on the case or to cause injury to the Veteran. Therefore, any such error is harmless and does not prohibit consideration of these matters on the merits. See Dingess, supra; see also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). Analysis Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2012). Evidence of continuity of symptomatology from the time of service until the present is required where the chronicity of a condition manifested during service either has not been established or might reasonably be questioned. 38 C.F.R. § 3.303(b). Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Moreover, where a veteran served continuously for ninety (90) days or more during a period of war, or during peacetime service after December 31, 1946, and hypertension or brain hemorrhage becomes manifest to a degree of 10 percent within one year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). In order to prevail on the issue of service connection, there must be medical evidence of a current disability; medical evidence, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and competent evidence of a nexus between an in-service injury or disease and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999); see also Barr v. Nicholson, 21 Vet. App. 303 (2007); Pond v. West, 12 Vet. App. 341, 346 (1999). Service connection may also be established for disability which is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a) (2012). Further, a disability which is aggravated by a service-connected disability may be service-connected to the degree that the aggravation is shown. 38 C.F.R. § 3.310 (2012); Allen v. Brown, 7 Vet. App. 439 (1995). The Board has reviewed all of the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims file shows, or fails to show, with respect to the claims. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Service treatment records are negative for any complaints, diagnoses, or treatment for hypertension or residuals of a stroke. On separation examination in July 1969, the Veteran's blood pressure was 132/72. He was not found to have any residuals of a stroke or hypertension. During the Veteran's period of service in the Army Reserves, a cardiology risk screening was performed in May 1992. The report showed blood pressure readings of 147/81 at rest and 205/85 at peak. The Veteran was diagnosed with coronary risk factors, and the physician concluded that the Veteran exhibited possible anterior wall aneurysm. In an October 1992 follow-up letter, a private medical physician reviewed the May 1992 results and concluded that the Veteran had an insignificant abnormality, and that the echocardiogram effectively ruled out the possibility for an anterior wall aneurysm. However, he noted that it was impossible to tell if there was a "congenital lesion." At a November 1994 physical, the Veteran's blood pressure was 160/108 and 150/90 upon repeat. The physician indicated that the Veteran had elevated or high blood pressure. Cardiovascular risk screenings were performed again in December 1994 and February 1995. Results revealed blood pressure readings of 160/108 and 160/90 in December 1994, and 146/89 at rest and 213/101 at peak in February 1995. The February 1995 report concluded that the Veteran was Functional Class I and negative for ischemic heart disease. Post-service medical records indicate that in October 2000, the Veteran suffered a left cerebrovascular accident with right-sided weakness. Private medical records dated from October 2000 to December 2009 show that the Veteran received intermittent treatment for status post left cerebrovascular accident with right-sided weakness, hypertension, carotid bruits, and multiple risk factors for coronary artery disease. An October 2008 carotid duplex scan revealed prominent hypoechoic to mixed echogenicity plaque that was lining both carotid bifurcations. There was evidence of stenosis through the proximal internal carotid artery on the right. Left vertebral flow was retrograde. A December 2009 carotid duplex scan showed essentially the same findings as the October 2008 scan, except for a slight increase in the peak systolic velocity through proximal internal carotid artery on the right. On VA cardiology examination in March 2010, the examiner noted that the Veteran had never had a heart attack and had never been at the hospital for a heart problem. The Veteran was also noted to have suffered a stroke in December 2000 that had left him with right hemiparesis, but with normal speech. The examiner also observed that in May 1992, a stress test had been normal, and an echocardiogram had suggested the possibility of an abnormal posterior wall hypokinesis but had been otherwise normal. All heart valves had also been normal. The Veteran reported that he was not aware that he had ever had any congenital heart abnormalities and that he had never been told of such a diagnosis. He also indicated that since his stroke, he had done well. He denied any current cardiac symptoms, to include chest pain, angina, palpitations, dizziness, orthopnea, or paroxysmal nocturnal dyspnea. He did report getting shortness of breath when walking short distances. The examiner noted that the Veteran had had high blood pressure for about 20 years. After a normal heart examination, the examiner found that there was no history of a congenital heart disease, clinical or echocardiographic evidence for a congenital heart disease, or evidence of any other heart disease at present. He explained that the very minimal abnormality seen in the May 1992 echocardiogram may have been a misinterpretation of the echocardiogram findings. In a May 2010 VA addendum opinion, the examiner reviewed additional private medical records that the Veteran had submitted and re-confirmed the findings of his March 2010 examination because other than a Doppler examination report of the carotid arteries, there was no report of cardiac studies or echocardiogram in the new medical evidence. In a February 2011 VA addendum, the examiner noted a February 2000 CT scan of the brain associated with the cerebrovascular accident that showed a basal ganglia bleed extending into the left side of the ventricles. The examiner found that the Veteran's cerebrovascular accident had been due to a bleed and not to an emboli. He noted that electrocardiograms and stress tests of 1992 and 1995 had all been normal. The examiner further explained that although an echocardiogram from that time had revealed a possible mild hypokinesia of the inferior wall, this finding had appeared to be more of a speculation than a diagnostic certainty. The examiner also opined that it was at least as likely as not that the Veteran's service-connected anxiety disorder might have worsened his hypertension, but that the anxiety would not have influenced the sequelae or residuals of a stroke. In a March 2011 VA addendum, the examiner clarified that regarding whether the Veteran's anxiety might have worsened his hypertension, it was only speculation on his part to assume that the anxiety could have influenced the Veteran's hypertension. He explained that this was because he had not seen the Veteran's baseline levels of hypertension, witnessed or examined the Veteran's anxiety over the years, or checked the Veteran's blood pressure over the years. At a December 2010 VA cardiology examination, the examiner again noted the Veteran's stroke in 2000, his negative history for heart attack or hospitalization for a heart problem, and the lack of current cardiac symptoms. The Veteran had a severe right hemiparesis, but maintained that he walked a lot to supermarkets and that he could walk 2 to 3 blocks at a slow pace. After a normal heart examination, the examiner determined that there was no clinical evidence of ischemic heart disease despite the fact that the Veteran had several risk factors for coronary artery disease, including a strong family history of coronary artery disease as well as a personal history of hypertension, smoking, and hyperlipidemia. Since there was no current evidence of ischemic heart disease, the examiner opined that it was less than 50 percent probability that exposure to herbicides had had any effect on the Veteran's heart disabilities. On VA cardiology examination in October 2011, the Veteran denied any current cardiac symptoms and reported that he was able to walk with the assistance of a cane up to 0.5 mile at his own pace and without stops. He indicated that he had first known of the presence of hypertension in 2000 when he had his stroke but had not known of hypertension prior to that. The examiner noted that his previous statement in his March 2010 examination report of the Veteran having had high blood pressure for 20 years was erroneous. The examiner also found that although the Veteran had several risk factors for ischemic heart disease, such as hypertension, hyperlipidemia, strong family history of arteriosclerosis, and a severe history of smoking, there was no clinical evidence of any cardiac disease, and therefore, no cardiac disability existed at the present time. The examiner found that there was a gap of 31 years between service and the presence of hypertension in 2000. He therefore opined that there was less than 50 percent probability for any connection between service and the development of high blood pressure. He explained that the Veteran had essential hypertension, for which there was no known cause or etiology, and that at the time of the last examination, he had been normotensive just as he had been on examinations conducted after his stroke. The examiner also opined that the degree of anxiety that the Veteran had experienced over the years was not an etiological cause for high blood pressure but that it could affect the level of blood pressure. He again explained that this was pure speculation because he had never treated the Veteran during an anxiety episode and seen what the blood pressure level had been at the time. The examiner further opined that there was no relationship between the Veteran's anxiety and his stroke residuals of right hemiparesis because the hemiparesis was due to an anatomical damage of the brain and had no relationship to anxiety. He concluded that there was less than 50 percent probability that the Veteran's hypertension and stroke residuals were proximately due to or the result of a service-connected anxiety disorder. In a December 2011 VA addendum, the examiner reiterated his opinion that the Veteran's hypertension was first documented in 2000 and that there had been a 31-year gap where the Veteran had not been treated for hypertension. He again opined that there was less than a 50 percent probability that the Veteran's hypertension had any relationship with his period of service. The examiner also concluded that there was less than 50 percent probability that the Veteran's stroke residuals were related to his period of service, as they were instead due to intracerebral bleeding. At a December 2011 VA general examination, the Veteran reported that he had been found to have elevated blood pressure in 2001 when he had had his stroke. He stated that he was subsequently hospitalized for 2 months and that after discharge from the hospital, he was prescribed medication that he took for a year. He maintained that he had not had any problems with high blood pressure since then and that his blood pressure was in fact on the low side. He also indicated that since the stroke, he was able to move his right arm a little bit and that he generally tried to walk as much as he could. He reported being able to walk 0.5 mile with a cane outside of home and being able to walk without a cane at home while holding on to the table, chair, or couch. He stated that he used a cane because he would sometimes fall. He maintained that he had not been hospitalized for his stroke so far and that he saw the cardiologist every 6 months. He indicated that he was currently not taking any blood pressure medication because his blood pressure was now too low. The examiner noted that in a January 2009 medical record, the Veteran received an Axis I diagnosis of anxiety disorder, not otherwise specified. He had an Axis IV diagnosis of mild psychosocial and environment stressors associated with his stroke. After examination, the examiner reviewed the entire claims file and found that although it was possible that a health condition related to stress, such as anxiety, depression, and isolation from friends and family, may be linked to heart disease, there was no evidence that these stresses were linked to high blood pressure. The examiner cited a June 2010 statement from the American Heart Association and the 2007 edition of the American Journal of Hypertension in support of this finding. He concluded that the Veteran's hypertension was therefore not at least as likely as not caused by his service-connected anxiety. On VA neurology examination in December 2011, the Veteran reported a sudden onset of light-headedness and confusion in October 2000. He stated that he had no memory of what had occurred in the subsequent 2 hours and that when he "came to," he was in a hospital, where he remained for 3 weeks. He indicated that he was diagnosed as having experienced a left cerebral hemorrhage that had caused him to become paralyzed on the right side and initially have difficulty with speech. He maintained that he underwent physical and occupational therapy for 6 weeks after discharge from the hospital. He denied being on current specific medication for his stroke. He reported using a cane to ambulate because of his hemiplegia. He also stated that his speech had returned to almost normal over the years and denied any visual difficulty. He did complain of occasional tingling sensation in the right upper extremity. The Veteran was diagnosed with cerebrovascular accident (cerebral hemorrhage) in the left cerebral hemisphere. The examiner explained that this diagnosis had been established based upon careful review of the claims file, information obtained from the present history, and the results of the neurologic examination. He opined that the Veteran's stroke was less likely than not proximally due to or the result of his service-connected anxiety disorder. The examiner also found that it was less likely than not that the stroke had been aggravated by the service-connected anxiety disorder. He explained that the cause of the stroke was diffuse cerebral vascular disease and not anxiety. As an initial matter, the Board notes that the Veteran has not alleged that he has a congenital heart disability. However, the evidence has raised the possibility that the Veteran has a heart disability that is congenital in nature. Specifically, an October 1992 private physician indicated that it was impossible to tell if a May 1992 echocardiogram had revealed a congenital lesion. Service connection for congenital, developmental, or familial diseases can be granted if manifestations of the disease in service constitute aggravation of the condition. 38 C.F.R. §§ 3.303, 3.304, 3.310 (2012); VAOPGCPREC 82-90 (July 18, 1990); 56 Fed. Reg. 45711 (1990). However, a March 2010 VA examination found no history of a congenital heart disease or clinical or echocardiographic evidence for any congenital heart disease. The VA examiner explained that the very minimal abnormality seen in the May 1992 echocardiogram may have been a misinterpretation of the echocardiogram findings. As the March 2010 VA examiner reviewed the claims file, interviewed and examined the Veteran, and provided adequate reasoning and bases for the finding that the Veteran had no congenital heart disease, his opinion is afforded great probative value. Therefore, the Board finds that service connection is not warranted on the basis of aggravation of a congenital disorder. Additionally, a presumption of exposure to herbicides exists for veterans who served on active duty in the Republic of Vietnam during the period from January 9, 1962 to May 7, 1975. 38 C.F.R. § 3.307(a)(6) (2012). If a veteran was exposed to Agent Orange or another herbicide agent, service connection for any of the conditions listed under 38 C.F.R. § 3.309(e), including ischemic heart disease, may be presumed if the condition becomes manifest to a degree of 10 percent disabling or more. 38 C.F.R. §§ 3.307(a)(6), 3.309(e) (2012). In this case, the Veteran's service personnel records confirm that he served in Vietnam from November 1968 to March 1969. However, the evidence does not show that the Veteran has a diagnosis of ischemic heart disease. Indeed, on VA examination in December 2010, the examiner acknowledged that the Veteran had several risk factors for coronary artery disease, but still determined that there was no clinical evidence of any ischemic heart disease. Since there was no current evidence of ischemic heart disease, the examiner opined that it was less than 50 percent probability that exposure to herbicides had had any effect on the Veteran's heart disabilities. As the December 2010 VA examiner reviewed the claims file, interviewed and examined the Veteran, and provided adequate reasoning and bases for the finding that the Veteran had no ischemic heart disease that was due to exposure to herbicides, his opinion is afforded great probative value. With regard to service connection for hypertension on a direct basis, the Board reiterates that the Veteran's service treatment records are negative for any complaints, diagnosis, or treatment of hypertension. The Veteran's Army Reserve records only show two incidents of elevated blood pressure in November 1994 and December 1994. Additionally, at no time did any of the Veteran's treating providers find that his hypertension was due to any period of service. The October 2011 and December 2011 VA examiner reviewed the claims file, interviewed and examined the Veteran, and provided adequate reasoning and bases for the opinion that it was less likely than not that the Veteran's hypertension was caused by his service. The examiner cited the gap in time between discharge from service and the first post-service evidence of hypertension. He also explained that the Veteran had essential hypertension, for which there was no known cause or etiology, and noted that the Veteran had been normotensive on his last examination and on examinations after his stroke in 2000. For these reasons, the October 2011 opinion with December 2011 addendum by the October 2011 VA examiner is afforded great probative value. As noted, the Board has considered all of the Veteran's periods of service. The probative and persuasive evidence fails to show that his hypertension was incurred in or aggravated by any period of active duty, to include any period of inactive duty for training. Additionally, since hypertension is not an injury, consideration of the Veteran's inactive duty for training periods is not required. 38 U.S.C.A. §§ 101, 1110, 1131 (West 2002); 38 C.F.R. §§ 3.6, 3.303 (2012). With regard to service connection for hypertension on a secondary basis, the Board notes that at no time did any of the Veteran's treating providers find that his hypertension was due to or aggravated by his anxiety disorder. However, the VA examiner who performed the October 2011 and December 2011 VA examinations and provided the February 2011 and March 2011 addendum opinions reviewed the claims file, interviewed and examined the Veteran, and provided adequate reasoning and bases for the opinions that it was less likely than not that the Veteran's hypertension was caused by his anxiety disorder, and that it was less likely than not that the Veteran's hypertension had been aggravated by his anxiety disorder. Specifically, the December 2011 VA examiner cited medical literature indicating that although it was possible that a health condition related to psychological stress may be linked to heart disease, there was no evidence that these stresses were linked to high blood pressure, and therefore the Veteran's hypertension was not due to his anxiety disorder. Additionally, although the Veteran was not able to provide an opinion regarding whether the Veteran's hypertension was aggravated by his anxiety disorder without resorting to speculation, an examiner's conclusion that a diagnosis or etiology opinion is not possible without resort to speculation is considered to be a medical conclusion just as much as a firm diagnosis or a conclusive opinion if the reason that speculation would be required is explained. The Board may rely on such a conclusion if the examiner explains the basis for such an opinion, bases the opinion on sufficient facts or data, and clearly identifies precisely what facts cannot be determined. Additionally, the examiner may have an obligation to conduct research in the medical literature depending on the evidence in the record at the time of the examination. Jones v. Shinseki, 23 Vet. App. 382 (2010). In the present case, the VA examiner explained in a March 2011 addendum opinion that he could not determine whether the Veteran's anxiety disorder had aggravated his hypertension because he had not seen the Veteran's baseline levels of hypertension, witnessed or examined the Veteran's anxiety over the years, or checked the Veteran's blood pressure over the years. In October 2011, the VA examiner reiterated that he had not treated the Veteran during an anxiety episode and seen the corresponding blood pressure level. The Board finds that the VA examiner adequately explained the reasons that speculation would be required. For these reasons, the February 2011 and March 2011 VA addendum opinions and the October 2011 and December 2011 VA opinions by the VA examiner are afforded great probative value. With regard to service connection for residuals of a stroke on a direct basis, the Board reiterates that the Veteran's service treatment records and Army Reserve records are negative for any complaints, diagnosis, or treatment of residuals of a stroke. Additionally, at no time did any of the Veteran's treating providers find that his residuals of a stroke were due to or incurred in any period of service. Indeed, the evidence showed that the Veteran suffered a stroke in 2000, which is several years after his period of service. However, the December 2011 VA examiner reviewed the claims file, interviewed and examined the Veteran, and provided adequate reasoning and bases for the opinion that it was less likely than not that the Veteran's residuals of a stroke were caused by his period of service. The examiner explained that the stroke was not due to service but that it was instead due to intracerebral bleeding. For these reasons, the December 2011 VA addendum opinion is afforded great probative value. Again, the Board has considered all of the Veteran's periods of service. The probative and persuasive evidence fails to show that his stroke or residuals therefrom was incurred in or aggravated by any period of active duty. The Veteran's sustained no acute myocardial infarction, cardiac arrest, or cerbrovascular accident while on active duty, active duty for training, or inactive duty for training. 38 U.S.C.A. §§ 101, 1110, 1131 (West 2002); 38 C.F.R. §§ 3.6, 3.303 (2012). With regard to service connection for residuals of a stroke on a secondary basis, the Board notes that at no time did any of the Veteran's treating providers find that his residuals of a stroke were due to or aggravated by his anxiety disorder. However, the October 2011 and December 2011 VA examiner reviewed the claims file, interviewed and examined the Veteran, and provided adequate reasoning and bases for the opinions that it was less likely than not that the Veteran's residuals of a stroke were caused by his anxiety disorder, and that it was less likely than not that the Veteran's residuals of a stroke had been aggravated by his anxiety disorder. The examiner explained that the stroke was not due to anxiety but instead due to diffuse cerebral vascular disease. He also cited the careful review of the claims file, information obtained from the present history, and the results of the neurologic examination in support of his opinions. For these reasons, the October 2011 and December 2011 opinions are afforded great probative value. The Board notes that the Veteran has been diagnosed with hypertension and residuals of a stroke (brain hemorrhage), which are conditions explicitly recognized as chronic under 38 C.F.R. § 3.309(a) (2012). Service connection based on a continuity of symptomatology can be warranted under 38 C.F.R. § 3.303(b) (2012) for chronic diseases. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). However, in this case, the Veteran has not asserted having hypertension or a stroke in service, nor has he asserted a continuity of symptomatology after discharge. Indeed the Veteran has reported at VA examinations that he had not had any problems with hypertension prior to his stroke in 2000. Additionally, he has not indicated that he had a stroke or residuals of a stroke prior to 2000. Moreover, the objective evidence of record does not show that the Veteran has continuously had hypertension or residuals of a stroke since discharge from service. Therefore, the Board finds that service connection for hypertension or residuals of a stroke based on a theory of continuity of symptomatology is not warranted. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issues in this case, hypertension and residuals of a stroke fall outside the realm of common knowledge of a lay person. In this regard, while the Veteran can competently report the onset and symptoms of shortness of breath or right-sided numbness, any actual diagnoses of hypertension or residuals of a stroke require objective testing to diagnose, and can have many causes. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). Moreover, whether symptoms the Veteran experienced in service or following service are in any way related to any current hypertension or residuals of a stroke requires medical expertise to determine. See Clyburn v. West, 12 Vet. App. 296, 301 (1999) ("Although the veteran is competent to testify to the pain he has experienced since his tour in the Persian Gulf, he is not competent to testify to the fact that what he experienced in service and since service is the same condition he is currently diagnosed with."). To the extent that the Veteran himself believes that he has current hypertension and residuals of a stroke that are due to service, exposure to herbicides, or a service-connected disability, as a lay person, he is not shown to possess any specialized training in the medical field. The Veteran's opinions as to the etiology of his current hypertension and residuals of a stroke are not competent medical evidence, as such questions require medical expertise to determine. Id. In any event, the Board concludes that the medical evidence, which reveals that hypertension and residuals of a stroke are not due to service, exposure to herbicides, or a service-connected disability, is of greater probative value than the lay contentions of the Veteran. In sum, the Board finds that the probative and persuasive evidence establishes that the Veteran did not have chronic hypertension or residuals of a stroke in service, and there is no competent and credible evidence indicating he had hypertension or brain hemorrhage manifested to a compensable degree within a year following discharge from service. Likewise, the weight of the competent and probative evidence does not show the Veteran's current hypertension and residuals of a stroke are related to his period of service, to include his exposure to herbicides therein, or that his current hypertension and residuals of a stroke are due to or aggravated by his service-connected anxiety disorder. Accordingly, service connection for hypertension and residuals of a stroke is not warranted on any basis. In reaching the conclusions above, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claims, that doctrine is not applicable in the instant appeal. See 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). ORDER Entitlement to service connection for hypertension, to include as secondary to service-connected anxiety disorder, is denied. Entitlement to service connection for residuals of a stroke, to include as secondary to service-connected anxiety disorder, is denied. ____________________________________________ C. CRAWFORD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs