Citation Nr: 1315795 Decision Date: 05/14/13 Archive Date: 05/15/13 DOCKET NO. 04-19 992 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to service connection for stress fractures of the bilateral lower legs. 2. Entitlement to service connection for residuals of mononucleosis. 3. Entitlement to service connection for bilateral hearing loss. 4. Entitlement to service connection for hypertension, to include as secondary to service-connected disabilities. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD A.M. Ivory, Counsel INTRODUCTION The Veteran had active military service from January 1971 to January 1974. This matter comes before the Board of Veterans' Appeals (Board) on appeal from September 2003 and October 2006 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina. The September 2003 rating decision denied entitlement to service connection for diabetes mellitus, neuropathy secondary to diabetes mellitus, heart disease, jungle rot of the bilateral feet, and hypertension secondary to diabetes mellitus. The Veteran filed a timely substantive appeal and in June 2006 the Board denied entitlement to service connection for jungle rot and remanded the issues of entitlement to service connection for diabetes mellitus, neuropathy secondary to diabetes mellitus, heart disease, and hypertension secondary to diabetes mellitus. During the pendency of the appeal the March 2008 rating decision granted the Veteran service connection for type II diabetes mellitus with bilateral upper extremity peripheral neuropathy with an initial rating of 20 percent effective October 11, 2002; service connection for diabetic neuropathy of the right lower extremity with an initial rating of 20 percent effective October 11, 2002; service connection for diabetic neuropathy of the left lower extremity with an initial rating of 20 percent effective October 11, 2002; service connection for erectile dysfunction with a noncompensable evaluation effective June 6, 2007; and special monthly compensation based on the loss of use of a creative organ effective June 6, 2007. The remaining issues of entitlement to service connection for hypertension and heart disease both to include secondary to service-connected diabetes mellitus were developed and sent to the Board; however, in January 2009 and September 2010 the Board remanded both issues for further development. During the pendency of the appeal a September 2011 rating disease granted the Veteran service connection for coronary artery disease status post myocardial infarction effective July 10, 2003; thus, that issue was fully granted and it is no longer before the Board. In April 2012 the Board decided that a VHA opinion was required for the issue of entitlement to service connection for hypertension secondary to service-connected disabilities and in May 2012 a VHA opinion was rendered and in August 2012 a VHA addendum opinion was rendered. An April 2005 rating decision granted the Veteran non-service-connected pension effective December 14, 2004, denied service connection for posttraumatic stress disorder (PTSD), and deferred service connection for tinnitus and bilateral hearing loss; the Veteran then filed a Notice of Disagreement (NOD) in April 2005 for the denial of service connection for PTSD. By way of the October 2006 rating decision the RO granted the Veteran service connection for amputation of the distal fat pad of the left middle finger with an initial evaluation of 10 percent effective July 21, 2006, and denied service connection for degenerative disc disease of the lumbar spine, tinnitus, chronic obstructive pulmonary disease, chronic otitis media, bilateral hearing loss, mononucleosis, and stress fractures. The Veteran filed a substantive appeal on the issues of entitlement to service connection for tinnitus, chronic obstructive pulmonary disease, chronic otitis media, mononucleosis, and stress fractures. In an April 2007 statement the Veteran withdrew his claim for entitlement to service connection for chronic obstructive pulmonary disease, thus that issue is no longer on appeal. He also withdrew his request for a formal hearing, opting instead to an informal conference with a decision review officer. Such conference was held in April 2007 and there has been no mention or request for any other hearing. During the pendency of the appeal, a July 2007 rating decision granted the Veteran service connection for PTSD with an initial rating of 70 percent effective December 13, 2004, service connection for tinnitus with a 10 percent disability rating effective December 13, 2004, total disability based upon individual unemployability effective December 13, 2004, and basic eligibility to Dependent's Educational Assistance established from December 13, 2004. In March 2008, the RO granted service connection for chronic right otitis medial. Thus, the remaining issues on appeal are entitlement to service connection for hypertension, bilateral hearing loss, residuals of mononucleosis, and bilateral stress fractures of the lower legs. A review of the Virtual VA paperless claims processing system reveals additional VA treatment records; however, they do not pertain to the issues on appeal. Thus, the Veteran is not prejudiced from continuing with the adjudication of the appeals. The issue of entitlement to service connection for bilateral hearing loss is remanded to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. All notification and development action needed to fairly adjudicate the issues herein decided has been accomplished. 2. Extending the benefit of the doubt to the Veteran, bilateral stress fractures of the lower legs is shown as likely as not to be due to active service. 3. The Veteran had one in-service incident of mononucleosis; however, there is no evidence of a current diagnosis of any residuals of mononucleosis. 4. Hypertension was not present in service or for many years thereafter, and it was not caused or aggravated by service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for establishing service connection for bilateral stress fractures of the lower legs have been met. 38 U.S.C.A. § 1110, 1131, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2012). 2. The criteria for establishing service connection for residuals of mononucleosis have not been met. 38 U.S.C.A. § 1110, 1131, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2012). 3. The criteria for establishing service connection for hypertension are not met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310(a) (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist The Veterans Claims Assistance Act (VCAA), codified, in part, at 38 U.S.C.A. § 5103, was signed into law on November 9, 2000. Implementing regulations were created and are codified as amended at 38 C.F.R. § 3.159 (2012). VCAA notice consistent with 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) must: (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1) (2012). The United States Court of Appeals for Veterans Claims (Court) held in Pelegrini v. Principi, 18 Vet. App. 112 (2004) that to the extent possible the VCAA notice, as required by 38 U.S.C.A. § 5103(a) (West 2002), must be provided to a claimant before an initial unfavorable decision on a claim for VA benefits. Pelegrini, 18 Vet. App. at 119-20; see also Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The RO sent the Veteran correspondences in July 2003, January 2005, August 2005, July 2006, August 2006, February 2009, and September 2010. The VCAA letters indicated the types of information and evidence necessary to substantiate the claims, and the division of responsibility between the Veteran and VA for obtaining that evidence, including the information needed to obtain lay evidence and both private and VA medical treatment records. The July 2006, August 2006, February 2009, and September 2010 letters also informed the Veteran of the criteria of the applicable disability ratings and effective date elements of his claims. Dingess v. Nicholson, 19 Vet. App. 473 (2006); see also Mayfield and Pelegrini, both supra. In addition, the Veteran's claims were readjudicated by a July 2007 Supplemental Statement of the Case (SSOC) and a December 2011 SSOC. Accordingly, the Board finds that no prejudice to the Veteran will result from adjudication of his claims at this time. All relevant evidence necessary for an equitable resolution of the issues herein decided has been identified and obtained, to the extent possible. The evidence of record includes the Veteran's service treatment records, VA treatment reports, VA examinations, and statements from the Veteran and his representative. The Veteran was provided VA examinations in May 2007, October 2009 with an addendum opinion in April 2010, and October 2010; in May 2012 and August 2012 VHA opinions were rendered. The Board finds that these examinations are sufficient since they were thorough and contemporaneous examinations of the Veteran that took into account records of pre-service treatment, service treatment records, and records of post-service examination and treatment. Lineberger v. Brown, 5 Vet. App. 367 (1993); Waddell v. Brown, 5 Vet. App. 454 (1993); Caffrey v. Brown, 6 Vet. App. 377 (1994). The Veteran has not indicated that he has any further evidence to submit to VA, or which VA needs to obtain. There is no indication that there exists any additional evidence that has a bearing on this case that has not been obtained. The Veteran and his representative have been accorded ample opportunity to present evidence and argument in support of his appeal. Thus, the Board finds that VA has obtained, and made reasonable efforts to obtain, all evidence that might be relevant to the issues herein decided, and that VA has satisfied the duty to assist. All pertinent due process requirements have been met. See 38 C.F.R. § 3.103 (2012). II. Analysis Service connection may be granted for disability resulting from disease or injury incurred or aggravated during a Veteran's active service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303(a). If a condition noted during service is not shown to be chronic, then generally a showing of continuity of symptomatology after service is required for service connection. 38 C.F.R. § 3.303(b). Service connection may be granted for any disease diagnosed after discharge from service when all the evidence, including that pertinent to service, establishes that the disease was incurred during service. 38 C.F.R. § 3.303(d). Alternatively, when a disease at 38 C.F.R. § 3.309(a) is not shown to be chronic during service or the one year presumptive period, service connection may also be established by showing continuity of symptomatology after service. See 38 C.F.R. § 3.303(b). When such chronic diseases are at issue, the second and third elements for service connection may be established by showing continuity of symptomatology. Walker v. Shinseki, ___ F.3d ___, No. 2011-7184, 2013 WL 628429 (Fed. Cir. Feb. 21, 2013). However, the use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309(a). Id. When all the evidence is assembled, 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 a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Bilateral Stress Fractures of the Lower Legs The Veteran asserts that he currently has bilateral stress fractures of the lower legs as the result of his military service. After a careful review of the Veteran's claims file and granting the Veteran the benefit of doubt, service connection for bilateral stress fractures of the lower legs is warranted. According to the Veteran's service treatment records, at the time the Veteran was diagnosed with infectious mononucleosis in June 1971 it was noted that the Veteran was being treated for stress fractures that he developed in April 1971 and was currently being treated by the medical platoon for his stress fractures. However, the Veteran's January 1974 Report of Medical Examination for Separation had normal checked for his lower extremities. At the Veteran's May 2007 VA examination the Veteran reported that he had bilateral fractures of the lower tibia in 1971 in boot camp; he went to medical and was put on bed rest. He also stated that he was diagnosed with stress fractures and the pain has become worse since 1971. The Veteran stated that he used a cane, a wheelchair, and a shower chair for the stress fractures and he was unable to stand more than five minutes and was unable to walk more than ten to fifteen steps. The VA examiner stated that she was awaiting x-ray results of the tibia/fibula bilaterally for a diagnosis of stress fractures and that the Veteran had extreme pain on palpation on the lower third of the tibia/fibula bilaterally. After reviewing the x-ray studies she stated that she did not see any evidence of current or prior fracture on this examination; however, stress fractures of the tibia and fibula may be difficult to pick up on plain radiographs if they were incurred in the remote past. The Board finds that even though x-ray studies did not confirm bilateral stress fractures of the lower extremities, there is sufficient evidence indicating a diagnosis of bilateral stress fractures. The Veteran service treatment records show treatment for stress fractures. The Veteran has asserted currently having the same symptoms he had in service concerning the pain in his leg. The Board finds that his assertions are competent and credible. On VA examination there was objective evidence of the Veteran having extreme pain on palpation of the lower third of the tibia/fibula, bilaterally. The VA examiner, for the most part, indicated that stress fractures could be present but that they were difficult to pick up on plain radiography. Given the totality of the evidence, to particularly include the credible lay assertions concerning in-service onset and subsequent continuity of the Veteran's symptoms, and the VA examiner's opinion indicating that the Veteran could currently have bilateral stress fractures which were not demonstrated on radiographic studies, the Board will resolving all reasonable doubt in finding that the Veteran currently has bilateral stress fractures which is related to service. Consequently, the Board finds that the criteria for service connection for bilateral stress fractures of the lower extremities are met. Residuals of Mononucleosis The Veteran asserts that he currently has residuals of his in-service mononucleosis. However, after a careful review of the Veteran's claims file the Board finds that the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for residuals of mononucleosis. A careful review of the Veteran's service treatment records indicate that in June 1971 the Veteran was diagnosed with infectious mononucleosis. However, the Veteran's January 1974 Report of Medical Examination for Separation was silent for any residuals. At the Veteran's May 2007 VA examination he reported that during boot camp he was diagnosed with mononucleosis and was hospitalized. He also reported that they removed cysts from the nasal canals and the only time that it bothered him was when it gets cold, his glands swell and he gets severe fatigue. The Veteran was then diagnosed with no chronic residuals of mononucleosis. The Board finds that there is no evidence in the Veteran's post-service treatment records and service treatment records that he has a current diagnosis of residuals of mononucleosis. In Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007), the Federal Circuit determined that lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition (noting that sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer), (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. The relevance of lay evidence is not limited to the third situation, but extends to the first two as well. Whether lay evidence is competent and sufficient in a particular case is a fact issue. Here, however, there is no evidence that the Veteran ever reported any residuals of mononucleosis to his private or VA physicians and a VA physician has affirmatively ruled out any residuals thereof. Thus, the lay evidence of record does not establish current disability here. Without competent evidence of a current disability of residuals of mononucleosis service connection cannot be granted. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (Court stated "Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability," and held "[i]n the absence of proof of a present disability[,] there can be no valid claim"); Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). The Board finds that though the Veteran had treatment and a diagnosis of mononucleosis in service there is no evidence of a current diagnosed disability of residuals of mononucleosis. While the Veteran received treatment in service for mononucleosis during boot camp his service treatment records otherwise reflect that the Veteran did not complain of, or seek treatment for, any residuals since his diagnosis in 1971. In fact, the separation examination in January 1974 yielded normal findings, and other post-service evidence likewise indicates no disability manifested by residuals of mononucleosis. That a condition or injury occurred in service alone is not enough; there must be a disability resulting from that condition or injury. Degmetich v. Brown, 104 F.3d 1328, 1332 (Fed. Cir. 1997); Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992); Brammer v. Derwinski, 3 Vet. App. 223 (1993). Existence of current disability must be shown by competent medical evidence. Degmetich v. Brown, 104 F.3d 1328 (1997). "Current disability" means a disability shown by competent medical evidence to exist at the time of the award of service connection. Chelte v. Brown, 10 Vet. App. 268 (1997). Therefore, the Board finds that service connection must be denied. In sum, the Board finds that after a careful review of the Veteran's claims file service connection must be denied because there is no current diagnosed residuals of mononucleosis. Though the Veteran was treated during service for mononucleosis there is no evidence of any diagnosed residuals. Therefore, service connection is not warranted. Hypertension Service connection may also be granted for disability that is proximately due to or the result of a service-connected disability. See 38 C.F.R. § 3.310(a). The controlling regulation has been interpreted to permit a grant of service connection not only for disability caused by a service-connected disability, but for the degree of disability resulting from aggravation of a nonservice-connected disability by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. See 38 C.F.R. § 3.310(a); Harder v. Brown, 5 Vet. App. 183, 187 (1993). The Veteran reported that his current diagnosis of hypertension is secondary to his service-connected disabilities. The Board notes that he originally asserted it was secondary to his service-connected diabetes mellitus; however, during the pendency of the appeal he then asserted that it was the result of any of his service-connected disabilities, to include diabetes mellitus, PTSD, and coronary artery disease. However, after a careful review of the Veteran's claims file the Board finds that the preponderance of the evidence is against the Veteran's claim on both a direct service connection basis and secondary service connection basis. The Veteran served on active duty from January 1971 to January 1974. The Veteran's service treatment records do not show any reports, complaints, or diagnoses of high blood pressure or hypertension. On the Veteran's January 1974 Report of Medical Examination for Separation the Veteran's blood pressure reading was 110/68 and there was no notation of hypertension. As documented below, the Veteran was diagnosed with hypertension in either May 2002 or October 2003 (the date seems to fluctuate based upon on the medical report). Thus, the evidence of record does not show, nor does the Veteran contend, that his hypertension was manifested during service or within the one-year after service; thus, the presumption of service connection does not attach. In May 2012 a VHA opinion was rendered and he stated that it was less likely than not that the Veteran's hypertension had its clinical onset during active service, is related to any in-service disease, event, or injury, or was diagnosed within one year of his discharge from military service in November 1974. The rationale for his opinion was that the Veteran's service treatment records were silent for any diagnosis or treatment of hypertension while in the military and the Veteran's seperation examination had blood pressure well within the normal range and that the Veteran was not diagnosed with hypertension until 28 years after his discharge from the military, in 2002, when he suffered a myocardial infarction. Thus, the only opinion of record for direct service connection is against the Veteran's claim; moreover, even the Veteran's own statements do not relate his hypertension directly to his military service. Thus, the Board finds that the preponderance of the evidence is against the Veteran's hypertension being directly related to his military service. Instead, the Veteran asserts that his hypertension is secondary to his service-connected disabilities. However, after a careful review of the Veteran's claims file, including the Veteran's statements, the Board finds that the preponderance of the evidence is against the Veteran's claim of secondary service connection. The Veteran asserts that he suffered a myocardial infarction in 2002 and was first diagnosed with chronic heart disease, diabetes mellitus, type II, and hypertension at this time. However, he also contends that he was previously told his blood sugar levels showed borderline diabetes in 1999 and reports that he had a long history of diabetic neuropathy symptomatology prior to his first formal diagnosis. The Veteran suffered a second myocardial infarction in 2003. Private treatment records from August 2002 and September 2002 show that the Veteran was seen for a follow-up appointment after the placement of two artery stents in July 2002. His problem list shows a diagnosis of hypertension and coronary artery disease, as well as a tentative diagnosis of diabetes mellitus, confirmed in October 2002. The notes show that the Veteran was taking lisinopril, 10 mg twice a day, at that time. As his blood pressure readings were still too high, his dosage was doubled. In December 2002, the Veteran returned for a blood pressure check. He was comfortable without apparent distress and his heart sounds were normal. His blood pressure is described as "well enough controlled" and the notes show that the Veteran was congratulated for his success in reducing his blood pressure. At that time his blood pressure reading was at 110/70. A month later his blood pressure was back up to 144/90 and in April 2003 it was 152/110. In February 2005, the Veteran was provided with a VA examination. He stated that he was in relatively good health until May 2002, when he had a myocardial infarction resulting in the placement of two stents. Subsequently, in May 2003, he had a second myocardial infarction and was hospitalized for a week. The VA examiner noted that during the Veteran's hospitalization for his heart attack, he was diagnosed with hypertension, diabetes mellitus, type II, hyperlipidemia, and peripheral neuropathy. He reported taking lisinopril, 20 mg twice a day, and metoprolol, 50 mg once daily. The Veteran stated that his blood pressure averaged 190/120 when he was not taking his medication and 120/80 with his medication. With regard to his diabetes mellitus, the Veteran stated that his kidneys have been affected. On examination his blood pressure readings were 130/76, left arm sitting; 131/85, left arm standing; 126/74, right arm sitting; and 130/76, right arm standing. The VA examiner diagnosed the Veteran with hypertension, currently controlled with medication, with evidence of coronary artery disease, and status post two myocardial infarctions with stent placement and chronic angina, requiring nitroglycerin patch for control. He was noted to be currently tolerating activities in the less-than-or-equal-to-3 metabolic equivalent of task (MET) range, mostly likely a result of his hyperlipidemia, hypertension, and diabetes mellitus, type II. In May 2007, the Veteran was provided with an additional VA examination. The Veteran reported that he suffered one myocardial infarction in 2002 and a second in 2003, at which time he was diagnosed with hypertension and diabetes. The Veteran reported that he did not do self checks at home, was unsure of his regular readings, and that he has not been hospitalized for hypertension. He was taking lisinopril and metoprolol. On examination his blood pressure reading was 130/80. The VA examiner diagnosed the Veteran with essential hypertension and opined that it was less likely than not, 50/50 probability, caused by or related to his diabetes mellitus since both were diagnosed within a relatively close period of time, approximately one year. In October 2009, the Veteran was afforded a VA examination and the examiner noted that the Veteran was diagnosed with diabetes and hypertension in 2003. The Veteran reported blood pressure readings averaging in the 100s/50s. At the examination, his blood pressure was 110/60. The VA examiner diagnosed the Veteran with essential hypertension and opined that it was not related to his diabetes. The VA examiner's rationale was that diabetes only caused hypertension in the presence of end-stage renal disease, which the Veteran did not exhibit. Furthermore, the VA examiner noted, his diagnoses of hypertension and diabetes were given at the same time in 2003. The VA examiner also opined that the Veteran's diabetes mellitus has not worsened or affected his hypertension, but no rationale for this opinion was provided. In an April 2010 VA memorandum the October 2009 VA examiner provided the same opinion as above. The Veteran underwent a VA examination in October 2010. The VA examiner noted that the Veteran was unaware of having hypertension, diabetes, or heart disease until he had a myocardial infarction in 2002. He reported taking medication for hypertension since that time and stated that he was first diagnosed with diabetes mellitus shortly after his first myocardial infarction. It was noted that the Veteran did not have nephropathy. The Veteran stated that he did not check his blood pressure at home. At the time of the examination it was 76/142. The Veteran reported taking the following medications: aspirin, furosemide, nitroglycerin, metoprolol, gemfibrozil, fenofibrate, and simvastatin. The Veteran again stated that he has never been hospitalized for hypertension, but was hospitalized for his heart in 2002 and 2003, and again in 2007 or 2008 for carotid surgery. The VA examiner diagnosed the Veteran with essential hypertension and stated the Veteran was diagnosed in July 2002 with hypertension. The VA examiner stated that there is no evidence that the Veteran has kidney nephropathy, which would be the reason that that the Veteran's hypertension would be secondary to or aggravated beyond normal course by type II diabetes mellitus. Therefore, it was her opinion that the Veteran's diagnosis of hypertension was not secondary to his service-connected diabetes mellitus, type II; she further stated that there was no evidence of kidney nephropathy, which is the only mechanism whereby hypertension can be caused or aggravated by diabetes mellitus, type II. In April 2012 the Board requested a VHA opinion; in May 2012, a VHA opinion was rendered and he stated that it was less likely than not that the Veteran's hypertension had its clinical onset during active service, is related to any in-service disease, event, or injury, or was diagnosed within one year of his discharge from military service in November 1974. The rationale for his opinion was that the Veteran's service treatment records were silent for any diagnosis or treatment of hypertension while in the military and the Veteran's seperation examination had blood pressure well within the normal range and that the Veteran was not diagnosed with hypertension until 28 years after his discharge from the military, in 2002, when he suffered a myocardial infarction. The VHA examiner then stated that it was less likely than not that the Veteran's hypertension is proximately due to his service-connected diabetes mellitus, coronary artery disease, or PTSD. The physician provided a rationale in support of his opinion. He noted that the Veteran had a diagnosis of essential hypertension which is a multi-factorial disease that can be caused by any number of recognized etiologies. However, in the absence of nephropathy, diabetes mellitus is not among them. Though he has both hypertension and diabetes (without evidence of nephropathy), there is no element of causality of one condition over the other. Hypertension is not caused by diabetes mellitus in the absence of nephropathy, and diabetes mellitus is not caused by hypertension. Additionally, essential hypertension can cause coronary artery disease, but coronary artery disease does not cause hypertension. PTSD has no bearing on the diagnosis or clinical course of hypertension. Also the combination of diabetes mellitus, coronary artery disease and PTSD does not affect hypertension, because hypertension is diagnostically and clinically independent of all these. He further stated that a review of the Veteran's medical records reveals that he is independently positive for all 4 modifiable risk factors for coronary artery disease: smoking hypercholesterolemia, diabetes mellitus and hypertension. Another listed risk factors was obesity. In August 2012, the VHA examiner rendered an addendum opinion. He stated that the Veteran's hypertension was less likely than not aggravated by his service-connected diabetes mellitus because in the absence of nephropathy diabetes mellitus does not have any effect on blood pressure. Since the Veteran does not have diabetic nephropathy, his diabetes mellitus will not aggravate his hypertension. He then stated that the Veteran's hypertension is less likely than not aggravated by his service-connected coronary artery disease. He stated that hypertension is a risk factor for coronary artery disease, along with diabetes mellitus, smoking, and cholesterol; poor control of these risk factors can worsen coronary artery disease and not the other way around. He also stated that the Veteran's hypertension was less likely than not aggravated by his service-connected PTSD. He then stated that PTSD is a mental health condition that may certainly cause a transient rise in blood pressure, as with other mental health conditions , such as during fright, stress, or anxiety (ex. "white coat syndrome" - when one's blood pressure rises due to the anxiety of a visiting doctor). However, PTSD does not affect the pathophysiology to cause or exacerbate the systemic condition of essential hypertension. He stated that in summary, instead of attempting to search for obscure aggravating factors of this Veteran's hypertension, it is essential in the proper evaluation of his claim to recognize and accept the clear and defined pathophysiological processes that are well outlined in the reputable medical literature. He then stated that "[s]tudies, such as one published by Sonne-Holm et al in the British Medical Journal examiner independent effects of weight change and attained body weight in the prevalence of arterial hypertension in obese and non-obese men." It demonstrated that changes in body weight have a great influence on arterial hypertension independent. Obesity and weight gain are major risk factors for hypertension and are also determinants of the rise/worsening in blood pressure that is commonly observed with aging. He stated that to put it simply, as one became increasingly more obese, hypertension becomes worse and that this veteran chose to lead a lifestyle that put him at risk for increasing obesity and consequently it aggravated his hypertension. The Board finds that the only probative opinions of etiology of record are against the Veteran's claim of entitlement to service connection for hypertension secondary to the service-connected disabilities. The Board finds that on the issue of hypertension being caused by the Veteran's service-connected diabetes mellitus there are five opinions of record (May 2007 VA examination, October 2009 VA examination, an April 2010 VA addendum opinion, an October 2010, a May 2012 VHA opinion, and an August 2012 VHA opinion). First, the Board finds that the May 2007 VA examination opinion is not probative because it is unclear and contradictory; the VA examiner stated that it was less likely than not that the Veteran's hypertension was secondary to the Veteran's diabetes mellitus, this would indicate a negative nexus opinion and thus, a denial. However, he also stated that it was a 50/50 probability, which puts the evidence in equipoise and would indicate a grant of service connection. Thus, the Board finds that the May 2007 VA examination opinion is not probative. On the question of whether the Veteran's hypertension was caused by his service-connected diabetes mellitus the remaining opinions (October 2009 VA examination, an April 2010 VA addendum opinion, October 2010 VA examination, a May 2012 VHA opinion, and an August 2012 VHA opinion) are found to be probative; however, they are against the Veteran's claim. In both the October 2009 VA examination report and the April 2010 VA addendum opinion the VA examiner stated that the rationale for his opinion was that diabetes mellitus only caused hypertension in the presence of end-stage renal disease, which the Veteran did not exhibit. In October 2010 the VA examiner stated that kidney nephropathy would be the reason for the Veteran's hypertension and the only mechanism whereby hypertension could be caused by diabetes mellitus; however, there was no evidence that the Veteran had kidney nephropathy. In addition, the May 2012 VHA examiner stated that it was less likely than not that the Veteran's hypertension was proximately due to his service-connected diabetes mellitus. In the August 2012 VHA addendum opinion it was stated that in the absence of nephropathy diabetes mellitus does not have any effect on blood pressure. Competent medical evidence includes statements from a person qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. 38 C.F.R. § 3.159(a)(1). As the aforementioned VA examiners and VHA examiners are so qualified, the medical opinions constitute competent medical evidence. The Board further finds that the VA examiners' medical findings are credible, based on their internal consistency and the VA examiners' duty to offer truthful opinions. Moreover, the examiners offered clear conclusions with supporting data as well as a reasoned medical explanation connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); 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"). Consequently, the Board assigns great probative value to the VA examiners' opinions. Therefore, the Board finds that the probative opinions of record are against the Veteran's claim that his hypertension was caused by his service-connected diabetes mellitus. On the question of whether the Veteran's hypertension was aggravated by his service-connected diabetes mellitus the two opinions of record (October 2010 VA examination and the August 2012 VHA addendum opinion) are found to be probative; however, they are against the Veteran's claim. In October 2010 the VA examiner stated that there is no evidence that the Veteran has kidney nephropathy, which would be the reason that that the Veteran's hypertension would be aggravated beyond a normal course by type II diabetes mellitus. She further stated that there was no evidence of kidney nephropathy, which is the only mechanism whereby hypertension can be aggravated by diabetes mellitus, type II. In the August 2012 VHA addendum opinion it was stated that since the Veteran does not have diabetic nephropathy, his diabetes mellitus will not aggravate his hypertension. Therefore, the Board finds that the two opinions on the question of whether the Veteran's hypertension was aggravated by the Veteran's diabetes mellitus are against the Veteran's claim. The Board finds that these opinions are probative because not only did the VA examiners give clear opinions but they also stated that the Veteran's hypertension was not aggravated by the Veteran's diabetes mellitus since the Veteran does not have any evidence of kidney nephropathy after reviewing the Veteran's claims file. Greater weight may be placed on one physician's than another's depending on factors such as the reasoning employed by the physicians and whether or not (and the extent to which) they reviewed prior clinical records and other evidence. Gabrielson v. Brown, 7 Vet. App. 36, 40 (1994). Moreover, the examiners offered clear conclusions with supporting data as well as a reasoned medical explanation connecting the two. See Nieves- Rodriguez, supra; Stefl, supra. Therefore, the Board finds that the probative opinions of record are against the Veteran's claim that his hypertension was aggravated by his service-connected diabetes mellitus. On the issue of whether the Veteran's hypertension was caused by his PTSD and/or coronary artery disease the Board finds that there is only one probative opinion of record (May 2012 VHA opinion with subsequent April 2012 VHA addendum); however, it is against the Veteran's claim. It was stated that it was less likely than not that the Veteran's hypertension was proximately due to his service-connected coronary artery disease or PTSD. The Board further finds that the VHA medical findings are credible, based on their internal consistency and the VHA examiner's duty to offer truthful opinions. Moreover, the opinion was rendered after reviewing prior clinical records and other evidence and the physician gave a complete rationale to support his conclusion. Gabrielson v. Brown, supra. Therefore, the Board finds that the probative opinion of record is against the Veteran's claim that his hypertension was caused by his service-connected PTSD and/or coronary artery disease. On the issue of whether the Veteran's hypertension was aggravated by his PTSD and/or coronary artery disease the Board finds that there is only one probative opinion of record (the August 2012 VHA addendum) and it is against the Veteran's claim. First, the August 2012 VHA addendum opinion stated that hypertension is a risk factor for coronary artery disease and can worsen coronary artery disease but it does not work the other way around. Next, the August 2012 VHA addendum opinion stated that PTSD may certainly cause a transient rise in blood pressure but it did not affect the pathophysiology to cause or exacerbate the systemic condition of essential hypertension. The Board further finds that the VHA medical findings are credible, based on their internal consistency and the VHA examiner's duty to offer truthful opinions. Moreover, the examiner offered clear conclusions with supporting data as well as a reasoned medical explanation connecting the two. See Nieves- Rodriguez, supra; Stefl, supra. Moreover, the opinion was rendered after reviewing prior clinical records and other evidence. Gabrielson v. Brown, supra. Therefore, the Board finds that the probative opinion of record is against the Veteran's claim that his hypertension was aggravated by his service-connected PTSD or coronary artery disease. The Board notes that the Veteran asserts that his hypertension is secondary to his service-connected disabilities. A layperson, such as the Veteran, is competent to testify in regard to the onset and continuity of symptomatology. Heuer v. Brown, 7 Vet. App. 379, 384 (1995); (Falzone v. Brown, 8 Vet. App. 398, 403 (1995); Caldwell v. Derwinski, 1 Vet. App. 466 (1991). However, in the instant case, the Board finds that the question regarding the potential relationship between the Veteran's hypertension and service-connected disabilities, to be complex in nature. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). In this regard, the question of causation involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the Veteran's own opinion is non-probative evidence. Generally, when a Veteran contends that a service-connected disorder has caused or aggravated a secondary disability, there must be competent medical evidence of such causation or aggravation. See Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995); Jones v. Brown, 7 Vet. App. 134 (1994). To prevail on the issue of secondary service causation, the record must show: (1) evidence of a current disability; (2) evidence of a service-connected disability; and, (3) medical nexus evidence establishing a connection between the current disability and the service-connected disability. Wallin, supra. However, in this case, the Board finds that the only probative opinions of nexus are against the Veteran's claim. Thus, the Board finds that service connection must be denied. In sum, the Board finds the preponderance of the evidence is against the Veteran's claim since the only probative opinions of record are against the Veteran's claim. The evidence does not support a finding that his hypertension is secondary to or aggravated by his service-connected disabilities. The preponderance of the evidence is against the Veteran's claim. Accordingly, the benefit of the doubt doctrine does not apply and the claim must be denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER Service connection for bilateral stress fractures of the lower extremities is granted. Service connection for residuals of mononucleosis is denied. Service connection for hypertension, to include as secondary to service-connected disabilities is denied. REMAND After a careful review of the Veteran's claims file the Board finds that further development is warranted for the issue of entitlement to service connection for bilateral hearing loss. For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater, or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, 4000 Hertz are 26 decibels or greater, or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. Also, the threshold for normal hearing is between 0 and 20 decibels, and higher threshold shows some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). The Veteran served from September January 1971 to January 1974; according to the Veteran's personnel file and statements he was a rifleman. The Veteran's service treatment records include a March 1973 Recommendation for MOS Change by the regimental surgeon; it was stated that the Veteran had a chronic middle ear problem that would be aggravated by continued exposure to loud noise and it was recommended that the Veteran's MOS be change to one that would preclude any continued exposure to loud noise and that he should be afforded the full benefits of the hearing conservation program. The only audiogram of record is the Veteran's January 1974 Report of Medical Examination for Separation which showed hearing within normal limits for VA purposes. The Board notes that the Veteran is currently service-connected for tinnitus and chronic otitis media. At the Veteran's September 2006 VA examination his ears were noted to be bilaterally normal with a remote history of recurrent otitis media. The Veteran was then afforded a VA audiological examination in May 2007. The Veteran reported that during his military service he was an infantryman with 10 months in combat in the Republic of Vietnam and had exposure to noise from helicopters, ship noise, and gun fire. After his military service he worked in a factory for one year and did carpentry work on and off for 30 years and was exposed to noise from power tools and heavy equipment. The Veteran's audiogram results indicate that the Veteran meets the criteria for bilateral hearing loss under 38 C.F.R. § 3.385. The VA audiologist stated that the Veteran's acoustic immittance test results were consistent with excessive negative middle ear pressure. The Veteran was diagnosed with normal to mild bilateral sensorineural hearing loss; no nexus opinion was given. In this regard, there are no medical opinions addressing the etiology of the Veteran's bilateral hearing loss of record; thus, the Veteran should be afforded a VA examination. The VA examiner should also review the Veteran's prior medical history before stating an opinion and provide a reasoned explanation for its conclusion. If the VA examiner cannot provide an opinion then he/she must provide a reasoned medical explanation of why he/she cannot give an opinion to the etiology of the Veteran's bilateral hearing loss. Prior to any VA examination, attempts should be made to obtain any outstanding records of pertinent medical treatment. Accordingly, the case is REMANDED for the following action: 1. The RO/AMC should take appropriate steps to contact the Veteran and request that he provide sufficient information, and if necessary authorization, to enable the RO/AMC to obtain any additional pertinent treatment records not currently of record. Based on his response, the RO/AMC should assist him in obtaining any additional evidence identified, following the current procedures set forth in 38 C.F.R. § 3.159. All records/responses received should be associated with the claims file. The RO/AMC should obtain all pertinent treatment records. The RO/AMC should obtain any pertinent treatment records. If any records sought are not obtained, the RO/AMC should notify the Veteran of the records that were not obtained, explain the efforts taken to obtain them, and describe the further action to be taken. 2. The RO/AMC shall schedule the Veteran for an appropriate VA examination to ascertain the nature and likely etiology of his bilateral hearing loss. The entire claims file must be made available to the examiner and the examination report should include discussion of the Veteran's medical history and assertions. All appropriate tests and studies (audiological studies and Maryland CNC test) should be accomplished and all clinical findings should be reported in detail. The VA examiner must answer all of the following questions: A) Does the Veteran have a current diagnosis of a bilateral hearing loss ? B) If the Veteran has a current diagnosis of bilateral hearing loss, the VA examiner must opine if the hearing loss is at least likely as not (probability of 50 percent or greater) related to the Veteran's military service, including his report of noise exposure in service. In giving an opinion, the examiner must review the Veteran's reported history as to the onset and continuity of symptomatology, as well as discuss the Veteran's inservice and postservice noise exposure history. Any opinions expressed must be accompanied by a complete rationale. If an opinion cannot be given without resorting to mere speculation than the VA examiner must state so and further provide a reason for such conclusion. 3. The RO should review the claims file to ensure that all the foregoing requested development is completed, and thereafter, arrange for any additional development indicated. The RO should then readjudicate the remaining issue on appeal. If any benefit sought remains denied, the RO should issue an appropriate SSOC (Supplemental Statement of the Case) and provide the Veteran and his representative the requisite time period to respond. The case should then be returned to the Board for further appellate review, if otherwise in order. 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). No action is required of the appellant until further notice. However, the Board takes this opportunity to advise the appellant that the conduct of the efforts as directed in this remand, as well as any other development deemed necessary, is needed for a comprehensive and correct adjudication of his claims. His cooperation in VA's efforts to develop his claim, including reporting for any scheduled VA examination, is both critical and appreciated. The appellant is also advised that failure to report for any scheduled examination may result in the denial of a claim. 38 C.F.R. § 3.655. 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. 2012). ______________________________________________ K. OSBORNE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs