Citation Nr: 1321498 Decision Date: 07/03/13 Archive Date: 07/12/13 DOCKET NO. 08-34 167 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for right knee disability. 2. Entitlement to service connection for left knee disability. 3. Entitlement to service connection for hypertension. 4. Entitlement to service connection for renal failure with frequent urination (renal disease) to include as secondary to hypertension. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD A. Fagan, Associate Counsel INTRODUCTION The Veteran served on active duty from September 1983 to September 1985. This matter came before the Board of Veterans' Appeals (Board) on appeal from a March 2007 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO). In August 2012, the Board remanded the appeal for additional development. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). The issues of service connection for hypertension and renal failure with frequent urination are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The preponderance of the evidence shows that the Veteran has not had a left knee disability at any time during the appeal period. 2. The preponderance of the evidence shows that the Veteran's right knee disabilities were not present in service or until many years thereafter, and are not related to service or to an incident of service origin. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a left knee disability have not been met. 38 U.S.C.A. §§ 1110, 1131, 1154(a), 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2012). 2. The criteria for entitlement to service connection for a right knee disability have not been met. 38 U.S.C.A. §§ 1110, 1131, 1154(a), 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Veterans Claims Assistance Act The Veterans Claims Assistance Act (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2012)) redefined VA's duty to assist the appellant in the development of a claim. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2012). The notice requirements of the VCAA require VA to notify the Veteran of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, the VA will attempt to obtain. 38 C.F.R. § 3.159(b) (2012). The requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between the Veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO). Id; see also Pelegrini v. Principi, 18 Vet. App. 112 (2004). However, insufficiency in the timing or content of VCAA notice is harmless if the errors are not prejudicial to the claimant. Conway v. Principi, 353 F.3d 1369, 1374 (Fed. Cir. 2004) (VCAA notice errors are reviewed under a prejudicial error rule). In this case, letters dated in December 2006, June 2008, April 2010, and August 2012 provided notice to the Veteran regarding what information and evidence was needed to substantiate his claims for service connection, including informing him of what information and evidence must be submitted by the Veteran and what information and evidence will be obtained by VA. Those letters also advised the Veteran of the evidence needed to establish a disability rating and effective date for the claim on appeal. The case was last readjudicated in April 2013. The record also reflects that VA has made reasonable efforts to obtain relevant records adequately identified by the Veteran. Specifically, the information and evidence that have been associated with the claims file include the Veteran's service treatment records, VA treatment records and examination reports, Social Security Administration records, and private treatment records. Additionally, the prior August 2012 remand instructions were substantially complied with. Instructions pertinent to the claims being decided included obtaining additional treatment records, lay statements, and scheduling the Veteran for appropriate VA examinations concerning his claims. In August 2012, the RO requested additional from the Veteran additional evidence or information relating to any providers who have rendered treatment relating to the knees. In January 2013, the Veteran submitted additional medical and lay evidence in support of his claims. The Veteran was also provided a VA examination in November 2012 concerning his knee claims, and an addendum opinion was obtained in March 2013 following the Veteran's January 2013 submission of additional evidence. Thus, the Board finds that there has been substantial compliance with the prior remand instructions and no further action is necessary. See D'Aries v. Peake, 22 Vet. App. 97 (2008) (holding that only substantial, and not strict, compliance with the terms of a Board remand is required pursuant to Stegall v. West, 11 Vet. App. 268 (1998)). As discussed above, the VCAA provisions have been considered and complied with. The Veteran was notified and aware of the evidence needed to substantiate these claims, the avenues through which he might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. The Veteran has been an active participant in the claims process by reporting for VA examinations, responding to notices, and submitting evidence and argument. Thus, the Veteran has been provided with a meaningful opportunity to participate in the claims process and has done so. Any error in the sequence of events or content of the notice is not shown to have affected the essential fairness of the adjudication or to cause injury to the claimant. Therefore, any such error is harmless and does not prohibit consideration of this matter on the merits. See Conway, supra; Dingess, supra; see also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). II. Service Connection Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (table). In the absence of proof of a current disability, there can be no valid claim. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (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. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77. The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a) (West 2002). Moreover, the United States Court of Appeals for Veterans Claims (Court) has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. See id. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See Id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). In a claim for service connection, the ultimate credibility or weight to be accorded evidence must be determined as a question of fact. The Board determines whether the weight of the evidence supports the claim, or the weight of the positive evidence in favor of the claim is in relative balance with the weight of the negative evidence against the claim, and the appellant prevails in either event. However, if the weight of the evidence is against the appellant's claim, the claim must be denied. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other issue, that reasonable doubt will be resolved in favor of the claimant. By reasonable doubt is meant one which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. 38 C.F.R. § 3.102 (2012). As an initial matter, the Board notes that the evidence of record sufficiently establishes that the Veteran has a right knee disability. Specifically, a March 2013 VA examination report shows diagnoses of degenerative joint disease of the right knee patellofemoral joint, gouty effusion of the right knee, and right knee villonodular synovitis. Thus, the analysis to follow will center on whether such right knee disabilities are related to military service. However, the preponderance of the evidence shows that the Veteran does not currently suffer from a left knee disability. The Veteran had a VA examination in November 2012. After examining him the examiner found that the Veteran had no left knee disability. The examiner found that left knee examination, including range of motion, stability, and strength testing, was normal. Furthermore, x-ray imaging of the left knee was within normal limits. The examiner did not diagnose the Veteran as having a left knee disability. That conclusion is consistent with the other medical evidence of record that is essentially negative for any left knee disability. The Veteran's VA treatment records are silent for left knee complaints or diagnoses. Similarly, with limited exception, private treatment records dating from September 2003 through July 2008 are negative for treatment related to the left knee. The Board recognizes that the Veteran was seen in November 2006 for complaints related to the left knee. In this regard, the Veteran initially sought treatment in October 2006 for left ankle symptoms of pain, mild swelling, and warmth. Gout was assessed at that time, and it was noted that the Veteran had a history of gout or pseudogout, and a history of left ankle pain and swelling six months prior. The next week, in November 2006, the Veteran returned stating that the pain had moved from is left ankle to his left knee. He also reported swelling in the left knee, and noted a history of similar symptoms related to gout. Physical examination revealed tenderness of the left lateral superior knee, but no evidence of effusion or warmth. Range of motion was full. A lower extremity ultrasound was performed given a history of deep vein thrombosis, but was negative for evidence of deep vein thrombosis. Clinical impression was arthritis. Significantly, however, it does not appear that the diagnosis was based on x-ray or other diagnostic imaging. Thereafter, the Veteran complained again of left knee pain during private January 2007 treatment. However, no diagnosis was given other than left knee pain. Similarly, private treatment records dated as recently as December 2012 show that, despite complaints of bilateral knee pain, physical examination of the left lower extremity, including range of motion, stability, and strength testing, was normal. The Board finds that the November 2012 VA examiner's opinion that the Veteran does not have a left knee disorder to be more probative and persuasive than the November 2006 clinical impression of arthritis, which was unsupported by objective findings or diagnostic imaging. The November 2012 VA examiner's opinion was based on a review of the claims file, a thorough physical examination, and notably, objective x-ray imaging of the left knee showing that the Veteran does not have arthritis. Moreover, the November 2012 examiner acknowledged the Veteran's November 2006 left knee complaints and indicated that migratory pains are not consistent with traumatic arthritis or osteoarthritis. Accordingly, the most probative evidence of record fails to show any left knee disability. Parenthetically, the Board is cognizant that a December 2006 private treatment record shows a diagnosis of left knee effusion, arthrocentesis, and acute inflammatory arthritis. However, the entirety of the treatment records of the same date show that the treatment on that date in December 2006 was in fact related to the right knee. The documented complaints, clinical findings, and diagrams at that time all relate to the right knee, and are entirely negative for references to the left knee. The Board thus finds that the December 2006 diagnosis of effusion and acute inflammatory arthritis was attributed to the left knee in error and, instead, related to the right knee. The only evidence that the Veteran suffers from a left knee disability comes from the Veteran's own statements and lay statements from his wife, mother, and sister. Regarding the latter, the Board finds those statements to be neither probative nor persuasive. The Veteran's wife, mother, and sister, have not been shown to have the requisite medical training necessary to diagnose any left knee disorder or attribute the Veteran's left knee symptoms to a diagnosis. Moreover, their statements are outweighed by the competent and credible objective findings noted on the November 2012 examination report, including x-ray imaging, indicating that the Veteran does not have a current left knee disability. Regarding the Veteran's own statements, the Board notes that even those statements are not entirely consistent with a current left knee disorder. In this regard, in an early January 2007 written statement, the Veteran referred to injuring his "knee" while in service, and reported his "knee" has been swelling and required draining. He did not report injury or symptoms related to both knees, but rather to a single knee. As the record shows that it is the Veteran's right knee that requires draining due to gout, the Board finds that the January 2007 statement refers to the right knee and is otherwise negative for left knee complaints. Thereafter, in his March 2008 notice of disagreement, the Veteran stated that he was submitting evidence showing that he developed osteoarthritis of his knees. However, the accompanying medical evidence relates to the right knee only. The Board cannot consider the Veteran's reports of osteoarthritis to be a competent relation of a contemporary diagnosis, as the most probative and objective medical evidence confirms that he does not suffer from this condition and diagnostic testing is necessary to identify the disability. In fact, despite the November 2006 private clinical impression of arthritis, the diagnosis was not supported by objective evidence, and subsequent objective findings or diagnostic testing during the November 2012 VA examination report show that the Veteran is not suffering from arthritis in his left knee. There is thus no competent report that the Veteran currently has any left knee pathology. The Board acknowledges the Veteran's lay statements indicating that he has left knee pain. The Board points out that, with few exceptions, the medical evidence is generally negative for left knee complaints despite documenting complaints relating to a variety of other disabilities. More significantly, clinical evaluation of the left knee has generally been within normal limits. Regardless, as detailed above, the Veteran has not been diagnosed as suffering from any left knee condition. The Court has consistently stated that pain alone is not a disability for which service connection may be granted. See, e.g., Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999), appeal dismissed in part, vacated and remanded in part sub nom. Sanchez-Benitez v. Principi, 259 F.3d 1356 (Fed. Cir. 2001). Absent any evidence that the Veteran suffers from a particular left knee disability other than pain, his claim must be denied. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) ("In the absence of proof of a present disability, there can be no valid claim."). Next, regarding the right knee, service treatment records are negative for clinical findings or complaints of any gout, arthritis, or other disability affecting the knees. Furthermore, the Veteran affirmatively denied "trick" or locked knee during an August 1985 separation examination, and clinical evaluation of the lower extremities at that time was normal. Significantly, the Veteran's August 1985 separation examination report shows a variety of other complaints by the Veteran. Post-service treatment records do not show evidence of any right knee disability related to service. Private treatment records show that in December 2000, while receiving treatment for right ankle pain, the Veteran denied a history of gout and the Veteran's right leg demonstrated full range of motion. Thereafter, private and VA treatment records dated from September 2003 to July 2008 show intermittent right knee complaints and findings of mild degenerative changes of the patellofemoral joint space of the right knee, inflammatory arthritis, and gout. Significantly, no private or VA provider attributed any right knee disability to service. As noted, the Veteran was afforded a VA joints examination in November 2012, at which time the VA examiner declined to diagnose any right knee disability. At that time, physical examination of the knees, including range of motion, stability, and muscle strength testing, was normal. The examiner noted that x-ray imaging of the right knee was normal, and that a 2007 MRI of the right knee did not show arthritic changes. The examiner further noted that despite the Veteran's claims of knee problems during active duty, service treatment records are negative for knee complaints. He noted that the knee symptoms and clinical findings shown in 2007 were not consistent with traumatic arthritis or osteoarthritis, but rather more consistent with gout or inflammatory arthritis. The examiner further found that the lay statements of record, including those of the Veteran and his mother, were not supported by the record. In March 2013, following the submission of additional evidence relating to the right knee, VA obtained an additional medical opinion. The examiner detailed a thorough review of the claims file including the additional evidence received since the November 2012 examination, and specifically acknowledged consideration of the Veteran's competent lay reports as to the onset and chronicity of right knee symptoms. The examiner diagnosed degenerative joint disease of the patellofemoral joint of the right knee, gouty effusion of the right knee, and villonodular synovitis of the right knee, and opined that each of the Veteran's right knee disorders is less likely as not caused by or a result of service. In support of the opinions, the examiner noted that service treatment records are silent for a right knee condition, and right knee pain was not shown until September 2003, almost 18 years post service. Moreover, the right knee x-ray at that time was normal, and in December 2005, 20 years post service, right knee imaging showed only mild degenerative changes in the patellofemoral space. The examiner further noted that gout is caused by elevated uric acid levels in the blood, which lead to inflammation of the knee, and was not diagnosed until 2006. In detailing the claims file, the examiner also noted that in December 2000, the Veteran denied a history of gout. The examiner further explained that villonodular synovitis results from the proliferation of the synovium of joints, bursae, and tendons, of uncertain etiology, and that record was silent for that condition until it was diagnosed in 2012. Finally, the March 2013 examiner noted that everyone that has had a fall on the knees has had acute knee pain, but that it is not indicative of a chronic condition. Presumably, the examiner is referencing the Veteran's assertions that he sustained knee injury in service when he fell in the woods. Conversely, the examiner noted that everyone who has chronic or recurrent knee pain had a first episode of knee pain, but that does not necessarily mean that the initial episode is related to the chronic condition. The examiner noted that while a knee sprain or strain involves the muscles and ligaments of the knee, degenerative joint disease is a degenerative process involving internal structure of the joint such as the bone and cartilage; gouty effusion is a fluid collection in the joint space; and villonodular synovitis involves the synovium of the joints, bursae, and tendons. Therefore, one is not the cause of or related to the other. Based on the findings of the November 2012 and March 2013 VA examiners, there is no medical evidence of a nexus (i.e., link) between the Veteran's right knee disabilities and his military service, such that service connection may be established. In fact, the only evidence in support of his claim under any theory of entitlement is the Veteran's belief that he has suffered from a right knee disorder since service. Based on review of the evidence, the Board finds that service connection for a right knee disorder is not warranted. At the outset, the evidence does not show that right knee arthritis was diagnosed to a compensable degree within a year of service. On the contrary, arthritis was not present on September 2003 imaging of the right knee, nearly 15 years after service. Furthermore, the Veteran's right knee gout and villonodular synovitis may not be presumed to have been incurred in service, as they are not recognized chronic disabilities for which service connection may be awarded on a presumptive basis. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013), overruling Savage v. Gober, 10 Vet. App. 488, 495-96 (1997) (applying 38 C.F.R. § 3.303(b) to a chronic disease not listed in 38 C.F.R. § 3.309(a) as "a substitute way of showing in-service incurrence and medical nexus"); 38 C.F.R. §§ 3.307, 3.309. The Veteran has competently reported that he has right knee symptoms. The service records do not, however, document a right knee disability, including DJD of the patellofemoral joint, gout, or synovitis, diagnosed in service. There is no evidence of a current right knee disability that has been related to service by way of competent medical evidence, or a credible report of a continuity of symptoms. Indeed, the March 2013 VA examiner opined that it is less likely than not that the current right knee disabilities are related to service. Further, the Veteran has not presented any additional competent medical evidence to dispute that opinion. Thus, the most probative evidence of record is the March 2013 VA opinion. As it relates to a continuity of symptoms, the Veteran has reported a continuity of right knee symptoms since service, and has submitted lay statements from his wife, mother, and sister, all attesting to knowledge of the Veteran's knee complaints in and post service. However, the Board finds those assertions not credible, as they are contradicted by other evidence of record. For example, while the Veteran and his family members have asserted that the Veteran was treated for right knee problems in service, his service treatment records are negative for records relating to the right knee, but do show him seeking service for other conditions. Even more probative, however, is the Veteran's contemporaneous and affirmative denial of knee problems on his August 1985 separation examination. Moreover, the Board finds probative the fact that when the Veteran first presented for right knee symptoms in September 2003, he did not report a history of any knee injury in service or persistent knee symptoms since service; instead, he reported a history of chronic right leg pain associated with prior nonservice-connected low back and right Achilles tendon injuries. That statement was made in furtherance of treatment and is accorded significant probative value. Thus, to the extent that the Veteran and his family members advance that the Veteran had an onset of right knee symptoms in service as well as ongoing and recurrent symptoms since separation to establish a nexus between a current right knee disability and service, the Board finds that their statements are not credible as they conflict with the contemporaneous evidence as determined by the Veteran's separation examination and his reported history upon seeking treatment for right knee symptoms in September 2003. Further, their lay contentions regarding the etiology of his current right knee disabilities are outweighed by the medical opinion provided by the examiner who reviewed the medical records, performed a clinical examination, and provided a cogent rationale in support of his assessment based on expertise acquired through education, training and experience. Cf. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). Because the preponderance of the evidence shows that a right knee disability manifested several years after service and is not related to or had its onset in service, service connection for a right knee disability must be denied. ORDER Service connection for a right knee disability is denied. Service connection for a left knee disability is denied. REMAND With respect to his hypertension claim, the Board observes that at service entry, the Report of Medical Examination reflects that the Veteran's blood pressure was recorded as 146/80. Additionally, it appears that the Veteran initially reported a history of high or low blood pressure on his September 1983 Report of Medical History upon entry into service, but subsequently, crossed out the checkmark placed under "YES" and then checked "NO." Subsequent service treatment records document both normal and high blood pressure readings. For example, in July 1984, the Veteran's blood pressure was recorded as 156/78, and in July 1985, it was 104/66 and 122/80. Further, at separation, the Report of Medical Examination shows that his blood pressure was recorded as 132/70, and the Veteran indicated on his Report of Medical History that he did not whether he had a history of high or low blood pressure. The Veteran filed this claim in November 2006 and he was afforded a VA hypertension examination in November 2012. The Board finds that the November 2012 VA hypertension examination opinion is inadequate for rating purposes. The examiner does not adequately address whether the Veteran's hypertension developed in service or within one year of his discharge. While the examiner found that the average of all of the blood pressure readings during the Veteran's active duty does not meet the criteria for a diagnosis of hypertension, he did not opine as to whether the elevated blood pressure readings noted in service were the initial manifestations of the Veteran's currently-diagnosed hypertension. Nor did the examiner address the Veteran's report on his August 1985 separation examination that he was not sure whether he had high or low blood pressure; that report suggests some indication that the Veteran had experienced blood pressure problems at some point prior to separation from service. Moreover, the examiner did not address an August 2001 private medical record noting that hypertension was diagnosed in December 1999 and that the Veteran's chronic renal insufficiency was related to his "longstanding hypertension." A June 2001 private record notes that the Veteran had renal failure since December 1999. The Board finds that the indication of longstanding hypertension sufficient to cause chronic renal in insufficiency in December 1999 suggests that the Veteran's hypertension likely even for some time prior to December 1999. Absent a discussion of the foregoing positive evidence, the November 2012 VA examination opinion does not provide a basis to properly evaluation the hypertension claim, requiring the Board to remand the appeal to obtain an adequate opinion. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Additionally, given the evidence that the Veteran's renal failure with frequent urination has been attributed to his hypertension, the claim must be deferred pending adjudication of the hypertension service connection claim. Parker v. Brown, 7 Vet. App. 116 (1994); Harris v. Derwinski, 1 Vet. App. 180 (1991) (issues are inextricably intertwined when a decision on one issue would have a significant impact on a Veteran's claim for another issue). Finally, as to his hypertension and renal failure claims, the Board finds that the record does not reflect sufficient attempt to obtain relevant private treatment records. In this regard, the Social Security Administration records identify providers for which no records have been obtained or requested. They also refer to treatment for hypertension and renal failure as early as December 1999; however, no records from that early treatment have been obtained. VA is obligated to attempt to obtain and consider these records in adjudicating this appeal. 38 U.S.C.A. § 5103A(c)(3) (West 2002); 38 C.F.R. § 3.159(c)(2) (2012). The Board thus has no discretion and must remand this appeal to attempt to obtain any outstanding records. Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). Expedited handling is requested.) 1. Notify the Veteran that he may submit lay statements from individuals with have first-hand knowledge, and/or who were contemporaneously informed, of his hypertension and chronic renal failure symptomatology or diagnoses; and medical statements in support of his claim, including from his medical care provider(s). 2. Contact the Veteran and request him to identify all sources of hypertension and chronic renal failure treatment, hospitalization and examination from private physician(s) and facility(ies), including private physician Dr. Walker, who treated the Veteran for hypertension and renal failure in December 1999. Thereafter, the RO should undertake appropriate efforts to obtain any indicated records. All development efforts should be associated with the claims file, to include obtaining notation that no additional records are available on the Virtual VA system if VA treatment records are identified. 3. Then schedule the Veteran for appropriate VA examinations to determine the nature, onset and etiology of any hypertension and chronic renal failure. The claims folder should be made available and reviewed by the respective examiner. The examiner should record the full history of the condition, to include the Veteran's account of symptomatology and onset. The examiner must identify all hypertension and chronic renal failure pathology found to be present. Thereafter, with regard to each diagnosed condition, please state the likelihood that the condition:(A) had its onset in service or within one year of separation; and (B) is related to the Veteran's period of military service, to include elevated blood pressure readings therein. The examination report must reflect the examiner's consideration and analysis of both the medical and lay evidence of record, including (I) the Veteran's account of symptomatology; (II) the September 1983 enlistment Report of Medical examination; (III) the elevated blood pressure reading in July 1984; (IV) the August 1985 separation Report of Medical examination; (V) private treatment records dated in June 2001 noting that December 1999, the Veteran had renal failure and hypertension, and dated in August 2001 noting chronic renal failure due to longstanding hypertension; and any other evidence deemed pertinent. All necessary testing should be completed with the relevant findings reported in detail. All provided opinions should be supported by a stated rationale. 4. Then, readjudicate the appeal. If the benefits sought on appeal remain denied, the Veteran and his representative should be provided with a Supplemental Statement of the Case (SSOC). An appropriate period of time should be allowed for response. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ STEVEN D. REISS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs