Citation Nr: 1320613 Decision Date: 06/26/13 Archive Date: 07/05/13 DOCKET NO. 08-01 805 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to service connection for a heart disorder, claimed as organic heart disease with ablation and pacemaker implantation (also claimed as chest pain and unstable angina). 2. Entitlement to service connection for hypertension. 3. Entitlement to service connection for residuals of a stroke. 4. Entitlement to service connection for an acquired psychiatric disorder, to include depression. 5. Entitlement to service connection for a disorder manifested by shortness of breath. 6. Entitlement to service connection for a disorder manifested by dizziness. 7. Entitlement to service connection for a disorder of the arms manifested by extremity numbness. 8. Entitlement to service connection for a disorder of the legs manifested by extremity numbness. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Kristy L. Zadora, Counsel INTRODUCTION The Veteran had active duty service from October 1980 to March 1984. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2007 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee, which denied the Veteran's claims for service connection for organic heart disease, hypertension, strokes, depression, shortness of breath, dizziness, and extremity numbness. Relevant to the Veteran's claim of entitlement to service connection for an acquired psychiatric disorder, the Board notes that, in Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009), the United States Court of Appeals for Veterans Claims (Court) held that, in determining the scope of a claim, the Board must consider the claimant's description of the claim; symptoms described; and the information submitted or developed in support of the claim. In light of the Court's decision in Clemons, the Board has recharacterized the issue on appeal as entitlement to service connection for an acquired psychiatric disorder, to include depression. A review of the Virtual VA claims processing system reveals VA treatment records dated through June 2009, which were considered in the June 2012 supplemental statement of the case (SSOC). The Board remanded the instant matters in August 2011. As will be discussed herein, the Board finds that the agency of original jurisdiction (AOJ) substantially complied with the remand order with regard to the claims for service connection for organic heart disease, hypertension, residuals of a stroke, depression, and shortness of breath and no further action is necessary in this regard. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). In a March 2012 VA examination report, the VA examiner indicated that the Veteran had been advised to file a claim for service connection for tinnitus. There is no indication that the Veteran has filed such a claim and this issue has not been adjudicated by the AOJ. Therefore, the Veteran is advised that, if he desires to file a claim for service connection for tinnitus, he should so inform the RO. The issues of entitlement to service connection for a disorder manifested by symptoms of dizziness and a disorder of the arms and legs manifested by symptoms of extremity numbness 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. A heart disorder is not shown to be causally or etiologically related to any disease, injury, or incident during service and did not manifest within one year of the Veteran's discharge from service. 2. Hyperlipidemia is a laboratory finding and is not considered a disability. 3. Hypertension is not shown to be causally or etiologically related to any disease, injury, or incident during service and did not manifest within one year of the Veteran's discharge from service. 4. Residuals of a stroke are not shown to be causally or etiologically related to any disease, injury, or incident during service and a brain thrombosis did not manifest within one year of the Veteran's discharge from service. 5. An acquired psychiatric disorder is not shown to be causally or etiologically related to any disease, injury, or incident during service. 6. A disorder manifested by shortness of breath, to include chronic obstructive pulmonary disease (COPD), is not shown to be causally or etiologically related to any disease, injury, or incident during service. CONCLUSIONS OF LAW 1. A heart disorder was not incurred in or aggravated by the Veteran's active duty service and may not be presumed to have been incurred in or aggravated by such service. 38 U.S.C.A. §§ 1101, 1112, 1131, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2012). 2. Hypertension was not incurred in or aggravated by the Veteran's active duty service and may not be presumed to have been incurred in or aggravated by such service. 38 U.S.C.A. §§ 1101, 1112, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2012). 3. Residuals of a stroke were not incurred in or aggravated by the Veteran's active duty service and may not be presumed to have been incurred in or aggravated by such service. 38 U.S.C.A. §§ 1101, 1112, 1131, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2012). 4. An acquired psychiatric disorder, to include depression, was not incurred in or aggravated by the Veteran's active duty service. 38 U.S.C.A. §§ 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2012). 5. A disorder manifested by shortness of breath, to include COPD, was not incurred in or aggravated by the Veteran's active duty service. 38 U.S.C.A. §§ 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between a Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. In Pelegrini v. Principi, 18 Vet. App. 112 (2004), the Court held that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable AOJ decision on the claim for VA benefits. Relevant to the claims adjudicated herein, the Board finds that VA has satisfied its duty to notify under the VCAA. Specifically, a June 2007 letter, sent prior to the initial September 2007 rating decision, advised the Veteran of the evidence and information necessary to substantiate his claims for service connection, as well as his and VA's respective responsibilities in obtaining such evidence and information. Additionally, such letter advised him of the information and evidence necessary to establish a disability rating and an effective date in accordance with Dingess/Hartman, supra. Relevant to the duty to assist, the Veteran's service treatment records, service personnel records, VA outpatient treatment records, various private treatment records, Social Security Administration (SSA) records, and VA examination reports have been obtained and considered. The Veteran has not identified any additional, outstanding records that have not been requested or obtained. In this regard, subsequent to the Board's remand, VA treatment records dated through June 2009 were obtained. Additionally, a January 2012 letter to the Veteran asked him to provide the names and addresses of all VA and non-VA health care providers who had treated him for the claimed disabilities. However, although the Veteran did submit additional private treatment records, he did not complete an appropriate authorization form to allow VA to obtain any additional records or identify any other VA or non-VA providers. The Board emphasizes that "the duty to assist is not always a one-way street. If a Veteran wishes help, he cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining the putative evidence." Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). Therefore, the Board finds that VA has satisfied its duty to assist in this regard. Additionally, the Veteran was afforded VA examinations in order to adjudicate his service connection claims. In this regard, the Board notes that the March 2012 VA examiners offered etiological opinions as to each claimed disorder and based their conclusions on interviews with the Veteran, a review of the record, and full examinations. Moreover, such opinions offered clear conclusions with supporting data as well as reasoned medical explanations 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"). As such, the Board finds that the opinions proffered by the VA examiners are sufficient to assist VA in deciding the instant claims. Moreover, based on the foregoing, the Board determines that the AOJ has substantially complied with the August 2011 remand directives in that a January 2012 letter requested that the Veteran identify any outstanding VA and non-VA treatment providers, obtained his updated VA outpatient treatment records, afforded the Veteran VA examinations as applicable to the instant claims, and readjudicated his claims in a June 2012 supplemental statement of the case. Therefore, no further action is necessary in this regard. See D'Aries, supra. Thus, the Board finds that VA has fully satisfied the duty to assist. In the circumstances of this case, additional efforts to assist or notify the Veteran in accordance with the VCAA would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements of the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the Veteran); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the Veteran are to be avoided). VA has satisfied its duty to inform and assist the Veteran at every stage in this case, at least insofar as any errors committed were not harmful to the essential fairness of the proceeding. Therefore, the Veteran will not be prejudiced as a result of the Board proceeding to the merits of his claims. II. Analysis Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. 38 U.S.C.A. § 1112; 38 C.F.R. § 3.304. See also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996) [(table)]. Where a Veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests certain chronic diseases, such as cardiovascular-renal disease, to include hypertension, and brain thrombosis to a degree of 10 percent within one year from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Service connection may also be established under 38 C.F.R. § 3.303(b) by (a) evidence of (i) a chronic disease shown as such in service (or within an applicable presumptive period under 38 C.F.R. § 3.307) and (ii) subsequent manifestations of the same chronic disease, or (b) if the fact of chronicity in service in not adequately supported, by evidence of continuity of symptomatology. However, the United States Court of Appeals for the Federal Circuit has held that the provisions of 38 C.F.R. § 3.303(b) relating to continuity of symptomatology can be applied only in cases involving those conditions explicitly recognized as chronic under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). A. Heart Disorder A July 1980 service entrance examination was negative for any relevant abnormalities and the Veteran denied heart trouble and pain or pressure in the chest in an accompanying Report of Medical History (RMH). The Veteran complained of shaking "a lot" in January 1982 and was assessed with anxiety. The remaining service treatment records were negative for complaints, treatments or diagnoses related to any heart disorder. A March 1984 service discharge examination was also negative for any relevant abnormalities and the Veteran again denied heart trouble and pain or pressure in the chest in an accompanying RMH. Post-service treatment records reflected the Veteran's complaints of intermittent substernal chest discomfort associated with a very fast tachyarrhythmia. The Veteran underwent ablation in 2002, 2003, and 2004 as well as a pacemaker implantation in November 2004. A November 2005 private carotid ultrasound indicated that the Veteran was free of significant atherosclerotic disease. In a June 2007 statement, the Veteran's spouse wrote that she had known the Veteran since 1985. She recalled that the Veteran experienced chest pains as early as 1985 or 1986. A March 2012 VA Disability Benefits Questionnaire (DBQ) report noted the Veteran's reports of experiencing chest pain, a rapid heartbeat and dizziness in 1981. These symptoms were treated as heartburn on three or four occasions. He further stated that, in 1986, after active duty, he was diagnosed with unstable angina and was later diagnosed with supraventricular tachycardia in 2000. Following a physical examination and a review of the Veteran's claims file, diagnoses of supraventricular arrhythmia, implanted cardiac pacemaker, and hyperlipidemia were provided. The examiner opined that it was less likely than not (less than a 50 percent probability) that such conditions were incurred in or caused by the claimed in-service injury, event or illness as there was no evidence of cardiopulmonary disease during service as the Veteran's blood pressure was normal. The examiner noted that the Veteran was also diagnosed with anxiety during service, of which the reported shakiness was a symptom. Further, the examiner noted that cardiac-related shakiness and palpitation will produce symptoms of poor cardiac perfusion such as chest pain, dizziness, shortness of breath, palpitation, syncope and fatigue. The examiner opined that there was no in-service record of an abnormal electrocardiogram nor was there any cardiac diagnosis within one year of separation from service. Post-service, the Veteran was evaluated for chest pain in August 1998, and a stress test was normal and denoted the absence of persistent arrhythmia, as noted by the examiner. Moreover, the examiner noted that the Veteran had risk factors for cardiac disease, including a prolonged history of tobacco use disorder since age 17, hypertension and hyperlipidemia. The Board has first considered whether service connection is warranted on a presumptive basis. However, the clinical evidence of record fails to show that the Veteran manifested cardiovascular-renal disease to a degree of 10 percent within the one year following his active duty service discharge in March 1984. With respect to the Veteran and his spouse's statements that he experienced symptoms of a heart disorder within a year of his discharge and such has continued to the present time, the Board finds that such are inconsistent with the contemporaneous evidence of record and were made in connection with his claim for VA benefits. Therefore, they are considered to be not credible. In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. See Caluza, supra. In this regard, a March 1984 service discharge examination was negative for any relevant abnormalities and the Veteran again denied heart trouble and pain or pressure in the chest in an accompanying RMH. Moreover, while the Veteran has reported treatment for a heart disorder in the mid-1980's, he has been given numerous opportunities to identify such records, but has not done so. See Wood, supra. Furthermore, the medical records contained in the claims file fail to reveal any reference to a heart disorder, to include by the Veteran's self-report, relevant to such time period. Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (ascribing heightened credibility to statements made to clinicians for the purpose of treatment); See Williams v. Gov. of Virgin Islands, 271 F.Supp.2d 696, 702 (V.I.2003) (noting that statements made for the purpose of diagnosis or treatment "are regarded as inherently reliable because of the recognition that one seeking medical treatment is keenly aware of the necessity for being truthful in order to secure proper care"). Furthermore, the examiner specifically determined that there was no cardiac diagnosis within one year of his service separation. Therefore, the Board finds that the Veteran did not manifest cardiovascular-renal disease, to include on the basis of continuity of symptomatology, within one year of his March 1984 discharge from service. As such, presumptive service connection is not warranted for a heart disorder. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309; Walker, supra. Service connection may be granted when all the evidence establishes a nexus between military service and current complaints. Degmetich v. Brown, 104 F. 3d 1328 (1997); Rabideau v. Derwinski, 2 Vet. App. 141 (1992). The medical evidence of record shows that the Veteran has diagnoses of supraventricular arrhythmia, implanted cardiac pacemaker, and hyperlipidemia. However, the probative evidence of record demonstrates that the Veteran's heart disorder, noted to be manifested by supraventricular arrhythmia, implanted cardiac pacemaker, and hyperlipidemia, is not related to his service. In this regard, the Board places great probative weight on the March 2012 VA examiner's opinion that the Veteran's heart disorder was less likely than not related to service as there was no evidence of cardiopulmonary disease during service and an August 1988 stress test was found to be normal without persistent arrhythmia. This opinion had clear conclusions and supporting data, as well as a reasoned medical explanation connecting the two. See Nieves-Rodriguez, supra; Stefl, supra. Accordingly, as the probative evidence of records demonstrates that the current heart disorder is not related to service, service connection is not warranted. The Board notes that the Veteran and his spouse have contended that his current heart disorder is related to his service. Lay witnesses are competent to provide testimony or statements relating to symptoms or facts of events that the lay witness observed and is within the realm of his or her personal knowledge, but not competent to establish that which would require specialized knowledge or training, such as medical expertise. Layno v. Brown, 6 Vet. App. 465, 469-70 (1994). Lay evidence may also be competent to establish medical etiology or nexus. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). However, "VA must consider lay evidence but may give it whatever weight it concludes the evidence is entitled to" and a mere conclusory generalized lay statement that service event or illness caused the claimant's current condition is insufficient to require the Secretary to provide an examination. Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). In the instant case, the Board finds that the question regarding the potential relationship between the Veteran's heart disorder and any instance of his service 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). Additionally, in a single-judge Memorandum Decision issued by the Court, it was noted that "in the absence of any medical evidence, the record must provide some evidence beyond an appellant's own conclusory statements regarding causation to establish that the appellant suffered from an event, injury or disease in service." Richardson v. Shinseki, No. 08-0357, slip. op. at 4 (Vet. App. May 10, 2010). While the Board recognizes that such single judge decisions carry no precedential weight, they may be relied upon for any persuasiveness or reasoning they contain. See Bethea v. Derwinski, 2 Vet. App. 252, 254 (1992). Here, while the Veteran and his spouse are competent to describe his current manifestations of his heart disorder as well as his history of treatment for such, the Board accords such statements regarding the etiology of such disorder little probative value as they are not competent to opine on such a complex medical question. Specifically, where the determinative issue is one of medical causation, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue. See Jones v. Brown, 7 Vet. App. 134, 137 (1994). In this regard, the diagnosis of a heart disorder requires the administration and interpretation of cardiovascular testing, such as stress tests. There is no indication that the Veteran or his spouse possess the requisite medical knowledge to perform cardiovascular testing or interpret their results. Moreover, as indicated previously, the Board has determined that the Veteran's and his spouse's statements regarding the onset of his heart disorder, to include treatment for such, to be not credible. Moreover, the Veteran and his spouse have offered only conclusory statements regarding the relationship between his in-service complaints of shakiness and his current heart disorder. In contrast, the March 2012 VA examiner took into consideration all the relevant facts in providing an opinion, to include the Veteran's contended in-service symptoms as well as the current nature of his heart disorder. Therefore, the Board accords greater probative weight to the VA examiner's opinion. Finally, with regard to the Veteran's diagnosed hyperlipidemia, the Board notes that such represents a laboratory finding and is not considered a disability for VA purposes. A disability for VA compensation purposes refers to an impairment of earning capacity due to a disease or injury, rather than to a disease or injury itself. Allen v. Brown, 7 Vet. App. 439 (1995). VA has determined that laboratory results are not, in and of themselves, disabilities. See Schedule for Rating Disabilities; Endocrine System Disabilities, 61 Fed. Reg. 20,440 (May 7, 1996). In response to the publication of the proposed rule, a commenter asked that VA address the handling of claims for Veterans receiving diagnoses of hyperlipidemia, elevated triglycerides, and elevated cholesterol. 61 Fed. Reg. 20440, 20445. The authors of the Final Rule responded: "[t]he diagnoses listed by the commenter are actually laboratory test results, and are not, in and of themselves, disabilities. They are, therefore, not appropriate entities of the rating schedule to address." Id. In this case, there is no indication that the Veteran's hyperlipidemia is manifested by any such impairment; the record does not reflect that a disability manifested by elevated cholesterol, such as the Veteran's heart disorder, is causally or etiologically related to any disease, injury, or incident in service. Consequently, the Board concludes the Veteran's claim of service connection for hyperlipidemia must be denied as a matter of law. See Sabonis v. Brown, 6 Vet. App. 426 (1994) (when the law and not the evidence is dispositive, a claim for entitlement to VA benefits should be denied or the appeal to the Board terminated because of the absence of legal merit or the lack of entitlement under the law). In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for a heart disorder. As such, that doctrine is not applicable in the instant appeal, and his claim must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. B. Hypertension A July 1980 service entrance examination was negative for any relevant abnormalities and the Veteran's blood pressure was measured to be 118/70. The Veteran denied high or low blood pressure in an accompanying RMH. His blood pressure was measured to be 90/56 in June 1981, 112/78 in January 1982, 98/62 in July 1982, 118/62 in August 1982, 132/78 in November 1982, 94/70 in November 1982, 100/58 in December 1982, 102/54 in November 1983, 110/70 in December 1982, 114/72 in February 1983, 92/58 in May 1983, 122/82 and 98/68 in June 1983, 102/58 in February 1984 and 102/70 in March 1984. A March 1984 service discharge examination was negative for any relevant abnormalities and the Veteran's blood pressure was measured to be 102/70. The Veteran again denied high or low blood pressure in an accompanying RMH. A post-service October 2003 private treatment note indicated that twenty-four hour ambulatory blood pressure monitoring had been performed and revealed hypertension. A March 2012 VA DBQ report noted that the Veteran had been diagnosed with hypertension in 2004. Following a physical examination and a review of the Veteran's claims file, the examiner opined that it was less likely than not (less than a 50 percent probability) that the Veteran's hypertension was incurred in or caused by the claimed in-service injury, event or illness. The examiner noted that the Veteran was diagnosed with hypertension in 2003, nine[teen] years after his service separation in 1984, and that he denied a history of shortness of breath and hypertension in February 1984. In addition, his blood pressure was noted to be 102/80 at his separation physical in March 1984. The Board has first considered whether service connection is warranted on a presumptive basis. However, the clinical evidence of record fails to show that the Veteran manifested hypertension to a degree of 10 percent within the one year following his active duty service discharge in March 1984. With respect to the Veteran and his spouse's statements that he experienced symptoms of a heart disorder, such as hypertension, within a year of his discharge and such has continued to the present time, the Board finds that such are inconsistent with the contemporaneous evidence of record and were made in connection with his claim for VA benefits. Therefore, they are considered to be not credible. In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. See Caluza, supra. In this regard, a March 1984 service discharge examination was negative for any relevant abnormalities and the Veteran's blood pressure was measured to be 102/70. Moreover, he denied high or low blood pressure in an accompanying RMH. Additionally, while the Veteran has reported treatment for a heart disorder in the mid-1980's, he has been given numerous opportunities to identify such records, but has not done so. See Wood, supra. Furthermore, the medical records contained in the claims file fail to reveal any reference to hypertension, to include by the Veteran's self-report, relevant to such time period. Rucker, supra; Williams, supra. Furthermore, the examiner specifically determined that there was no cardiac diagnosis within one year of his service separation. Therefore, the Board finds that the Veteran did not manifest hypertension, to include on the basis of continuity of symptomatology, within one year of his March 1984 discharge from service. As such, presumptive service connection is not warranted for hypertension. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309; Walker, supra. Service connection may be granted when all the evidence establishes a nexus between military service and current complaints. Degmetich, supra; Rabideau, supra. The medical evidence of record shows that the Veteran has a diagnosis of hypertension. However, the probative evidence of record demonstrates that the Veteran's hypertension is not related to his service. In this regard, the Board places great probative weight on the March 2012 VA examiner's opinion that the Veteran's hypertension was less likely than not related to service as he was not diagnosed with hypertension until 2003 and there were no in-service complaints or manifestations of hypertension. This opinion had clear conclusions and supporting data, as well as a reasoned medical explanation connecting the two. See Nieves-Rodriguez, supra; Stefl, supra. Accordingly, as the probative evidence of records demonstrates that the current hypertension is not related to service, service connection is not warranted. The Board notes that the Veteran and his spouse have contended that his current hypertension is related to his service. As previously noted, lay witnesses are competent to provide testimony or statements relating to symptoms or facts of events that the lay witness observed and is within the realm of his or her personal knowledge, but not competent to establish that which would require specialized knowledge or training, such as medical expertise. Layno, supra. Lay evidence may also be competent to establish medical etiology or nexus. Davidson, supra. However, "VA must consider lay evidence but may give it whatever weight it concludes the evidence is entitled to" and a mere conclusory generalized lay statement that service event or illness caused the claimant's current condition is insufficient to require the Secretary to provide an examination. Waters, supra. In the instant case, the Board finds that the question regarding the potential relationship between the Veteran's hypertension and any instance of his service to be complex in nature. See Woehlaert, supra. Additionally, in a single-judge Memorandum Decision issued by the Court, it was noted that "in the absence of any medical evidence, the record must provide some evidence beyond an appellant's own conclusory statements regarding causation to establish that the appellant suffered from an event, injury or disease in service." Richardson, supra. Here, while the Veteran and his spouse are competent to describe his current manifestations of hypertension as well as his history of treatment for such, the Board accords such statements regarding the etiology of hypertension little probative value as they are not competent to opine on such a complex medical question. Specifically, where the determinative issue is one of medical causation, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue. See Jones, supra. In this regard, the diagnosis of hypertension requires the administration and interpretation of blood pressure readings. There is no indication that the Veteran or his spouse possess the requisite medical knowledge to take blood pressure readings or interpret their results. Moreover, as indicated previously, the Board has determined that the Veteran's and his spouse's statements regarding the onset of his heart disorder, to include treatment for such, to be not credible. Moreover, the Veteran and his spouse have offered only conclusory statements regarding the relationship between his service and his current hypertension. In contrast, the March 2012 VA examiner took into consideration all the relevant facts in providing an opinion, to include the type of the Veteran's purported in-service injury and/or symptoms and the current nature of his hypertension. Therefore, the Board accords greater probative weight to the VA examiner's opinion. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for a hypertension. As such, that doctrine is not applicable in the instant appeal, and his claim must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. C. Residuals of a Stroke A July 1980 service entrance examination and a March 1984 service discharge examination were negative for any relevant abnormalities. The remaining service treatment records were negative for complaints, treatments or diagnoses related to a stroke. A March 2012 VA DBQ report reflected the Veteran's reports of experiencing dizziness, dysphasia, confusion and lethargy while at work in May 2005 and that subsequent diagnostic testing had revealed that he had suffered a stroke. Following a physical examination and a review of the Veteran's claims file, a diagnosis of a vascular disease, to include thrombosis, transient ischemic attack (TIA) or cerebral infarction, was made. The examiner opined that it was less likely than not (less than 50 percent probability) that this condition was incurred in or caused by the claimed in-service injury, event or illness. The examiner noted that the risk factors for stroke included hyperlipidemia, tobacco use disorder and hypertension while the primary risk factor for thrombotic stroke was hypertension, which the Veteran developed in 2003. The examiner noted that abnormal vascular pressure can dislodge unstable plaque, which occurred as a result of hyperlipidemia, and the Veteran reported being unaware of his cholesterol problem in August 1998. The Board has first considered whether service connection is warranted on a presumptive basis. However, the clinical evidence of record fails to show that the Veteran manifested a brain thrombosis to a degree of 10 percent within the one year following his active duty service discharge in March 1984. Moreover, neither the Veteran nor his spouse have alleged that he has manifested a continuity of symptoms associated with residuals of a stroke since his service discharge. Rather, they both state that the Veteran's stroke occurred in May 2005. Therefore, the Board finds that the Veteran did not manifest a brain thrombosis, to include on the basis of continuity of symptomatology, within one year of his March 1984 discharge from service. As such, presumptive service connection is not warranted for a brain thrombosis, or residuals of such. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309; Walker, supra. Service connection may be granted when all the evidence establishes a nexus between military service and current complaints. Degmetich, supra; Rabideau, supra. The medical evidence of record shows that the Veteran has a diagnosis of vascular disease. However, the probative evidence of record demonstrates that the Veteran's vascular disease is not related to his service. In this regard, the Board places great probative weight on the March 2012 VA examiner's opinion that the Veteran's vascular disease was less likely than not related to service as it was the result of other nonservice-related risk factors, to include hyperlipidemia, tobacco use disorder and hypertension. This opinion had clear conclusions and supporting data, as well as a reasoned medical explanation connecting the two. See Nieves-Rodriguez, supra; Stefl, supra. Accordingly, as the probative evidence of records demonstrates that the current vascular disease is not related to service, service connection is not warranted. The Board notes that the Veteran and his spouse have contended that his residuals of a stroke are related to his service. As previously noted, lay witnesses are competent to provide testimony or statements relating to symptoms or facts of events that the lay witness observed and is within the realm of his or her personal knowledge, but not competent to establish that which would require specialized knowledge or training, such as medical expertise. Layno, supra. Lay evidence may also be competent to establish medical etiology or nexus. Davidson, supra. However, "VA must consider lay evidence but may give it whatever weight it concludes the evidence is entitled to" and a mere conclusory generalized lay statement that service event or illness caused the claimant's current condition is insufficient to require the Secretary to provide an examination. Waters, supra. In the instant case, the Board finds that the question regarding the potential relationship between the Veteran's vascular disease and any instance of his service to be complex in nature. See Woehlaert, supra. Additionally, in a single-judge Memorandum Decision issued by the Court, it was noted that "in the absence of any medical evidence, the record must provide some evidence beyond an appellant's own conclusory statements regarding causation to establish that the appellant suffered from an event, injury or disease in service." Richardson, supra. Here, while the Veteran and his spouse are competent to describe his current manifestations of vascular disease and the treatment for such, the Board accords their statements regarding the etiology of such disorder little probative value as they are not competent to opine on such a complex medical question. Specifically, where the determinative issue is one of medical causation, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue. See Jones, supra. In this regard, the question of causation of vascular disease involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. There is no indication that the Veteran or his spouse possess the requisite medical knowledge to offer an opinion regarding the etiology of vascular disease. Moreover, the Veteran and his spouse have offered only conclusory statements regarding the relationship between his service and his current vascular disease. In contrast, the March 2012 VA examiner took into consideration all the relevant facts in providing an opinion, to include the type of the Veteran's purported symptoms and the current nature of his vascular disease. Therefore, the Board accords greater probative weight to the VA examiner's opinion. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for vascular disease. As such, that doctrine is not applicable in the instant appeal, and his claim must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. D. Acquired Psychiatric Disorder The Veteran contends that he was treated for depression during service and that his currently diagnosed depression was related to that treatment. A July 1980 service entrance examination was negative for any relevant abnormalities and the Veteran denied depression or nervous trouble of any sort in an accompanying RMH. Anxiety was assessed in January 1982 following complaints of shaking, nervousness and difficulty sleeping after experiencing a death in the family. In November 1983, the Veteran was treated in the mental health clinic with his spouse due to unspecified "marital issues." The remaining service treatment records were negative for complaints, treatments or diagnoses related to depression. A March 1984 service discharge examination was negative for any relevant abnormalities and the Veteran endorsed nervous trouble of any sort in an accompanying RMH. The examiner noted that this nervous trouble referred to job and family related problems, and that there were no complications and no sequelae (NCNS). A November 2006 private neuropsychological evaluation indicated that testing found that there were mild declines in multiple cognitive domains with some emotional overlays. A December 2008 VA treatment note reflected the Veteran's reports of mood swings, depression, and agitated spells since his stroke in May 2005. An April 2009 VA treatment note contained a diagnosis of a mood disorder due to a cerebrovascular accident (CVA). A March 2012 VA DBQ report reflects the Veteran's reports of experiencing depression during service as a result of being required to do things that were against his moral judgment and being away from home. Post-service, he first noticed depression after his 2005 stroke. Following a review of the Veteran's claims file and a mental status examination, diagnoses of depressive disorder with panic attacks and cognitive disorder not otherwise specified (NOS), by history were made. The examiner opined that it was less likely than not (less than a 50 percent probability) that this condition was incurred in or caused by the claimed in-service injury, event or illness as it was related to the Veteran's medical conditions, including his stroke and hypertension. The Veteran reported having panic attacks in relation to his cognitive deficits and the examiner opined that this symptom was directly related to his anxiety regarding memory disturbances and confusion. Service treatment records document the complaints of anxiety and nervousness due to work-related stress and family problems in service but were silent for complaints of depression. As the Veteran does not have a diagnosis of a chronic disease pursuant to VA regulations, he is not entitled to presumptive service connection for an acquired psychiatric disorder, to include on the basis of continuity of symptomatology. See Walker, supra. Service connection may be granted when all the evidence establishes a nexus between military service and current complaints. Degmetich, supra; Rabideau, supra. The medical evidence of record shows that the Veteran has a diagnosis of depression. However, the probative evidence of record demonstrates that the Veteran's depression is not related to his service. In this regard, the Board places great probative weight on the March 2012 VA examiner's opinion that the Veteran's depression was less likely than not related to service as his current complaints were related to his nonservice-related cognitive deficits. This opinion had clear conclusions and supporting data, as well as a reasoned medical explanation connecting the two. See Nieves-Rodriguez, supra; Stefl, supra. Accordingly, as the probative evidence of records demonstrates that the current depression is not related to service, service connection is not warranted. The Board notes that the Veteran and his spouse have contended that his current acquired psychiatric disorder is related to his service. As previously noted, lay witnesses are competent to provide testimony or statements relating to symptoms or facts of events that the lay witness observed and is within the realm of his or her personal knowledge, but not competent to establish that which would require specialized knowledge or training, such as medical expertise. Layno, supra. Lay evidence may also be competent to establish medical etiology or nexus. Davidson, supra. However, "VA must consider lay evidence but may give it whatever weight it concludes the evidence is entitled to" and a mere conclusory generalized lay statement that service event or illness caused the claimant's current condition is insufficient to require the Secretary to provide an examination. Waters, supra. In the instant case, the Board finds that the question regarding the potential relationship between the Veteran's acquired psychiatric disorder and any instance of his service to be complex in nature. See Woehlaert, supra. Additionally, in a single-judge Memorandum Decision issued by the Court, it was noted that "in the absence of any medical evidence, the record must provide some evidence beyond an appellant's own conclusory statements regarding causation to establish that the appellant suffered from an event, injury or disease in service." Richardson, supra. Here, while the Veteran and his spouse are competent to describe his current manifestations of acquired psychiatric disorder and the treatment for such, the Board accords their statements regarding the etiology of such disorder little probative value as they are not competent to opine on such a complex medical question. Specifically, where the determinative issue is one of medical causation, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue. See Jones, supra. In this regard, the question of causation of an acquired psychiatric disorder involves a medical subject concerning an internal psychological process extending beyond an immediately observable cause-and-effect relationship. There is no indication that the Veteran or his spouse possess the requisite medical knowledge to offer an opinion regarding the etiology of an acquired psychiatric disorder. Moreover, the Veteran has offered only conclusory statements regarding the relationship between his service and his depression. In contrast, the March 2012 VA examiner took into consideration all the relevant facts in providing an opinion, to include the type of the Veteran's purported symptoms and the current nature of his depression. Therefore, the Board accords greater probative weight to the VA examiner's opinion. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for an acquired psychiatric disorder. As such, that doctrine is not applicable in the instant appeal, and his claim must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. E. Shortness of Breath A July 1980 service entrance examination was negative for any relevant abnormalities and the Veteran denied shortness of breath in an accompanying RMH. The service treatment records are negative for complaints, treatments or diagnoses related to any pulmonary disability. A March 1984 service discharge examination was also negative for any relevant abnormalities and the Veteran again denied shortness of breath in an accompanying RMH. A March 2012 VA DBQ report reflects the Veteran's complaints of shortness of breath and dizziness and that this shortness of breath occurred concurrently with a rapid heart rate one to three times per week. The Veteran was noted to have had a long history of nicotine dependence as he continued to smoke less than one-half pack per day for 33 years. A history of asthma or lung disease were denied. Following a physical examination and a review of the Veteran's claims file, a diagnosis of COPD was made. The examiner opined that it was less likely than not (less than a 50 percent probability) that this condition was incurred in or caused by the claimed in-service injury, event or illness as there was no evidence of in-service pulmonary complaints. The examiner further opined that the COPD was the result of his prolonged tobacco use disorder. As the Veteran does not have a diagnosis of a chronic disease pursuant to VA regulations, he is not entitled to presumptive service connection for his disorder manifested by shortness of breath, diagnosed as COPD, to include on the basis of continuity of symptomatology. See Walker, supra. Service connection may be granted when all the evidence establishes a nexus between military service and current complaints. Degmetich, supra; Rabideau, supra. The medical evidence of record shows that the Veteran has a diagnosis of COPD. However, the probative evidence of record demonstrates that the Veteran's COPD is not related to his service. In this regard, the Board places great probative weight on the March 2012 VA examiner's opinion that the Veteran's COPD was less likely than not related to service as it was the result of his prolonged tobacco use disorder. This opinion had clear conclusions and supporting data, as well as a reasoned medical explanation connecting the two. See Nieves-Rodriguez, supra; Stefl, supra. Accordingly, as the probative evidence of records demonstrates that the current COPD is not related to service, service connection is not warranted. The Board notes that the Veteran and his spouse have contended that his current COPD is related to his service. As previously noted, lay witnesses are competent to provide testimony or statements relating to symptoms or facts of events that the lay witness observed and is within the realm of his or her personal knowledge, but not competent to establish that which would require specialized knowledge or training, such as medical expertise. Layno, supra. Lay evidence may also be competent to establish medical etiology or nexus. Davidson, supra. However, "VA must consider lay evidence but may give it whatever weight it concludes the evidence is entitled to" and a mere conclusory generalized lay statement that service event or illness caused the claimant's current condition is insufficient to require the Secretary to provide an examination. Waters, supra. In the instant case, the Board finds that the question regarding the potential relationship between the Veteran's COPD and any instance of his service to be complex in nature. See Woehlaert, supra. Additionally, in a single-judge Memorandum Decision issued by the Court, it was noted that "in the absence of any medical evidence, the record must provide some evidence beyond an appellant's own conclusory statements regarding causation to establish that the appellant suffered from an event, injury or disease in service." Richardson, supra. Here, while the Veteran and his spouse are competent to describe his current manifestations of COPD and the treatment for such, the Board accords their statements regarding the etiology of such disorder little probative value as they are not competent to opine on such a complex medical question. Specifically, where the determinative issue is one of medical causation, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue. See Jones, supra. In this regard, the question of causation of COPD involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. There is no indication that the Veteran or his spouse possess the requisite medical knowledge to offer an opinion regarding the etiology of his disorder manifested by shortness of breath, to include COPD. Moreover, the Veteran and his spouse have offered only conclusory statements regarding the relationship between his service and his current COPD. In contrast, the March 2012 VA examiner took into consideration all the relevant facts in providing an opinion, to include the type of the Veteran's purported symptoms and the current nature of his COPD. Therefore, the Board accords greater probative weight to the VA examiner's opinion. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for COPD. As such, that doctrine is not applicable in the instant appeal, and his claim must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. ORDER Service connection for a heart disorder is denied. Service connection for hypertension is denied. Service connection for residuals of a stroke is denied. Service connection for an acquired psychiatric disorder, to include depression, is denied. Service connection for a disorder manifested by symptoms of shortness of breath, to include COPD, is denied. REMAND Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran's claims for service connection for a disorder manifested by dizziness and a disorder of the arms and legs manifested by extremity numbness so that he is afforded every possible consideration. In addition, where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance. Stegall, supra. Once the Secretary undertakes the effort to provide an examination when developing a service connection claim, even if not statutorily obligated to do so, he must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). VA regulations provide that where an examination report does not contain sufficient detail, it is incumbent upon the rating board to return the report as inadequate for evaluation purposes. 38 C.F.R. §§ 4.2, 19.9. Where the Board makes a decision based on an examination report which does not contain sufficient detail, remand is required "for compliance with the duty to assist by conducting a thorough and contemporaneous medical examination." Goss v. Brown, 9 Vet. App 109, 114 (1996); Stanton v. Brown, 5 Vet. App. 563, 569 (1993). The Veteran generally contends that his dizziness and extremity numbness are related to service. Service treatment records documented complaints of dizziness in June 1983 but were negative for complaints of extremity numbness. In the August 2011 remand, the Board noted that both the Veteran and his spouse had provided competent statements regarding persistent or recurrent symptoms of a disability associated with such symptoms. As such, the Board remanded these claims to obtain an etiological opinion as to service connection. Such an opinion was obtained in March 2012. The VA examiner stated that the reported dizziness was not related to the Veteran's ears, but to his arrhythmia. This opinion, however, contained no rationale. A medical examination report must contain not only clear conclusions, but also a reasoned medical explanation connecting the two. See Nieves-Rodriguez, supra; Stefl, supra. In addition, while the VA examiner attributed the Veteran's left-sided muscle weakness to his cerebral vascular accident and paresthesias, no etiological opinion was provide as to extremity paresthesias. These opinions are therefore not sufficient to substantiate the claims. Therefore, a remand is necessary in order to obtain addendum opinions. Accordingly, the case is REMANDED for the following action: 1. Return the claims file, to include a copy of this remand, to the March 2012 VA examiner for an addendum opinion as to the nature and etiology of the Veteran's claimed disorder manifested by symptoms of dizziness. If the examiner who drafted the March 2012 opinion is unavailable, the opinion should be rendered by another appropriate medical professional. The need for another examination is left to the discretion of the medical professional offering the addendum opinion. Following a review of the claims file, the examiner is asked to furnish an opinion with respect to the following questions: (a) Identify all diagnoses related to the Veteran's complaints of dizziness. The examiner should identify all such disorders that have been present at any time since May 2007. (b) For each diagnosed disorder which manifested as dizziness, the examiner should offer an opinion as to whether it is at least as likely as not (50 percent or greater probability) that such disorder is related to the Veteran's military service, to include his in-service complaints of dizziness in June 1983. The examiner should also comment on the March 2012 findings that the Veteran's dizziness was related to his arrhythmias. The examiner should specifically consider the Veteran's lay statements regarding his dizziness. The rationale for any opinion offered should be provided. 2. Return the claims file, to include a copy of this remand, to the March 2012 VA examiner for an addendum opinion as to the nature and etiology of Veteran's claimed disorders manifested by symptoms of extremity numbness. If the examiner who drafted the March 2012 opinion is unavailable, the opinion should be rendered by another appropriate medical professional. The need for another examination is left to the discretion of the medical professional offering the addendum opinion. Following a review of the claims file, the examiner is asked to furnish an opinion with respect to the following questions: (a) Identify all diagnoses related to the Veteran's complaints of extremity numbness. The examiner should identify all such disorders that have been present at any time since May 2007. (b) For each diagnosed disorder which manifested as extremity numbness, the examiner should offer an opinion as to whether it is at least as likely as not (50 percent or greater probability) that such disorder is related to the Veteran's military service. The examiner should specifically consider the Veteran's lay statements regarding his extremity numbness. The rationale for any opinion offered should be provided. 3. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the Veteran's claims should be readjudicated based on the entirety of the evidence, to include all of the evidence received since the issuance of the June 2012 supplemental statement of the case. If the claims remains denied, the Veteran and his representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. Thereafter, the case should be returned to the Board for further appellate consideration, if otherwise in order. The Board intimates no opinion as to the outcome of this case. The Veteran need take no action until so informed. The purpose of this REMAND is to ensure compliance with due process considerations. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board 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). ______________________________________________ A. JAEGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs