Citation Nr: 1324968 Decision Date: 08/06/13 Archive Date: 08/13/13 DOCKET NO. 09-00 199 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to service connection for a gastrointestinal disorder, to include a hiatal hernia and duodenal ulcer. 2. Entitlement to service connection for a bilateral foot disability. 3. Entitlement to service connection for a left knee disability. 4. Entitlement to service connection for a psychiatric disorder, to include as secondary to a service-connected disability. 5. Entitlement to service connection for hypertension, to include as secondary to a service-connected disability. REPRESENTATION Appellant represented by: Georgia Department of Veterans Services WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Bernard T. DoMinh, Counsel INTRODUCTION The Veteran served on two separate periods of active duty in the United States Air Force. The first period was from July 1974 to July 1978 and the second period was from January 1980 to May 1984. This matter comes to the Board of Veterans' Appeals (Board) on appeal from multiple rating decisions issued by the Department of Veterans Affairs (VA) Regional Offices in St. Petersburg, Florida, and Atlanta, Georgia. Due to changes in the location of the Veteran's residence during the pendency of the claims, original jurisdiction over this current appeal has been transferred to the Atlanta, Georgia, VA Regional Office (RO). In October 2011, the Veteran, accompanied by his representative, appeared at the Atlanta RO to present evidence and oral testimony and arguments in support of his claims before the undersigned Veterans Law Judge. A transcript of this hearing has been obtained and associated with the Veteran's claims file for the Board's review and consideration. In a March 2012 appellate decision, the Board determined that new and material evidence had been received with respect to the claims for VA compensation for a gastrointestinal disorder, a bilateral foot disability, and a left knee disability, and reopened these claims for a de novo review on the merits. The aforementioned claims as well as claims for VA compensation for a psychiatric disorder and hypertension were then remanded to the RO via the Appeal Management Center (AMC) in Washington, D.C., for additional evidentiary and procedural development. Thereafter, the claims were readjudicated on the merits in a March 2013 rating decision/supplemental statement of the case, which denied service connection for a gastrointestinal disorder (to include a hiatal hernia and duodenal ulcer), a bilateral foot disability, a left knee disability, a psychiatric disorder (to include as secondary to a service-connected disability), and hypertension (to include as secondary to a service-connected disability). The case was returned to the Board in May 2013, and the Veteran now continues his appeal with respect to all of the aforementioned issues. For the reasons that will be discussed in the REMAND portion of this decision, the issues of entitlement to service connection for a bilateral foot disability and a psychiatric disorder are REMANDED to the RO via the RO/AMC, in Washington, D.C. The Veteran and his representative will be notified by VA if any further action in this regard is required of them. FINDINGS OF FACT 1. The Veteran has not been diagnosed worth a gastrointestinal disorder at any time during the pendency of this appeal. 2. A chronic left knee disability did not have its onset during active service. 3. Hypertension did not have its onset during active service and is not etiologically related to, or otherwise permanently worsened beyond its natural progression by a service-connected disability. CONCLUSIONS OF LAW 1. A chronic gastrointestinal disorder, to include a hiatal hernia and duodenal ulcer, was not incurred, nor is one presumed to have been incurred in active duty. 38 U.S.C.A. §§ 1110, 1111, 1112, 1113, 1131, 1137 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 2. A chronic left knee disability was not incurred, nor is one presumed to have been incurred in active duty. 38 U.S.C.A. §§ 1110, 1111, 1112, 1113, 1131, 1137 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 3. Hypertension was not incurred, nor is it presumed to have been incurred in active duty, and is not secondary to, or aggravated by a service-connected disability. 38 U.S.C.A. §§ 1110, 1111, 1112, 1113, 1131, 1137 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310(a), (b) (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's duties to notify and to assist The Board notes at the outset that, in accordance with the Veterans Claims Assistance Act of 2000 (VCAA), VA has an obligation to notify claimants what information or evidence is needed in order to substantiate a claim, as well as a duty to assist claimants by making reasonable efforts to get the evidence needed. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A and 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012); see also Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). Generally, the notice requirements of a service connection claim have five elements: 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 v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice must also: (1) inform the claimant about the information and evidence necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; (3) inform the claimant about the information and evidence the claimant is expected to provide; and (4) request that the claimant provide any evidence in his possession that pertains to the claim. See 38 U.S.C. § 5103(a); 38 C.F.R. § 3.159(b); Beverly v. Nicholson, 19 Vet. App. 394, 403 (2005) (outlining VCAA notice requirements). 38 C.F.R. § 3.159(b) has since been revised and the requirement that VA request that the claimant provide any evidence in his possession that pertains to the claim was removed from the regulation. The Veteran's claims for service connection decided herein were filed over the course of November 2006 - January 2007. Notice letters addressing the applicability of the VCAA to the claims and of VA's obligations to the appellant in developing the claims were dispatched in December 2006, January 2007, and March 2007 which, collectively, fully satisfied the above-described mandates. Additionally, the Veteran was given proper notice of the applicability of the VCAA in the context of reopening previously denied and final claims through submission of new and material evidence, in compliance with the holding of the decision of the United States Court of Appeals for Veterans Claims (Court) in the case of Kent v. Nicholson, 20 Vet. App. 1 (2006). (In this regard, the previously denied claims at issue have all been reopened for development and a de novo review on the merits.) No timing of notice defect exists as fully compliant notice was sent prior the initial comprehensive adjudication of the claims now on appeal before the Board by the agency of original jurisdiction in its rating decision of June 2007. [A March 2012 letter also provided such notice to the Veteran. The timing defect of this correspondence was cured by the AMC's readjudication of the claims and issuance of a supplemental statement of the case in March 2013.] VA also has a duty to assist the claimant in obtaining evidence necessary to substantiate a claim. 38 U.S.C.A. § 5103A(a) ("The Secretary shall make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate the . . . claim"). This duty includes assisting the claimant in obtaining records and providing medical examinations or obtaining medical opinions when such are necessary to make a decision on the claim. 38 U.S.C.A. § 5103A(b), (c), (d) (setting forth Secretary's various duties to claimant). VA informed the claimant of its duty to assist in obtaining records and supportive evidence. The Veteran was provided with the opportunity to present oral testimony in support of his claims before the undersigned Veterans Law Judge at the October 2011 hearing. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) (2012) requires that the Decision Review Officer or Veterans Law Judge who chairs a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) explaining fully the issues and (2) discussing the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010). At the October 2011 hearing, the presiding Veterans Law Judge's questions and the oral testimony of the Veteran focused on the elements necessary to substantiate, inter alia, the Veteran's claims for VA compensation for a gastrointestinal disorder, a left knee disability, and hypertension. [See transcript of October 20, 2011 Board hearing.] Thus, the Board finds that the Veterans Law Judge presiding over the October 2011 hearing has substantially fulfilled her obligations as required under 38 C.F.R. § 3.103(c)(2). Bryant, supra. Furthermore, in its remand of March 2012, the Board collectively instructed the RO/AMC to obtain the Veteran's service treatment records and any outstanding medical records relating to the Veteran's treatment for his claimed disabilities, and to provide him with the appropriate VA medical examinations for purposes of obtaining medical nexus opinions addressing the claimed disabilities at issue. Towards this end, a review of the claims file indicates that VA has obtained his service treatment records pertinent to both of his periods of active duty, as well as his post-service private, VA, and Social Security Administration (SSA) medical records from 1978 and for the period from 1986 - 2013. The Board has also reviewed the Veteran's claims file as it appears on the Virtual VA electronic database for any pertinent clinical records. Pursuant to the Board's remand of March 2012, VA provided the Veteran with VA examinations addressing the disabilities at issue in May 2012, in which definitive diagnoses and nexus opinions were obtained by the clinicians who examined the Veteran and had opportunity to review his pertinent clinical history contained in his claims file. The opinions specifically addressed the service connection issues on appeal. The Board finds that with the exception of the issues of entitlement to service connection for a bilateral foot disability and a psychiatric disorder, the physician's opinions of May 2012 are collectively deemed to be adequate for purposes of adjudicating the VA compensation claims decided herein, as they adequately address, contemplate, and incorporate the findings of the Veteran's pertinent clinical history and his prior treatments and examinations of record. See Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Thusly, in view of the foregoing discussion, the Board finds that the RO/AMC has substantially complied with its instructions regarding the evidentiary and procedural development ordered by the Board in its prior remand of March 2012 with respect to the claims for service connection for a gastrointestinal disorder, a left knee disability, and hypertension. Therefore, no additional remand for corrective action is required with respect to only these specifically aforementioned matters. [See Stegall v. West, 11 Vet. App. 268 (1998): A remand by the Board confers on a veteran or other claimant the right to VA compliance with the remand order and imposes on the Secretary a concomitant duty to ensure compliance with the terms of such an order. See also Dyment v. West, 13 Vet. App. 141, 146-47 (1999): Exact compliance with the directives of a Board remand are not necessarily required if the purpose of the remand has been met, such that the RO's post-remand development is in substantial compliance with the Board's remand instructions.] Based on the foregoing, the Board finds that VA fulfilled its VCAA duties to notify and to assist the claimant in the evidentiary development of his service connection claims decided herein, and thus no additional assistance or notification is required with respect to only these specific issues. The record shows that neither the Veteran nor his representative have indicated that they had any additional evidence or arguments to submit in support of the specific claims decided on the merits herein. He has suffered no prejudice in this regard that would warrant a remand, and his procedural rights have not been abridged as they pertain to these aforementioned matters. Bernard v. Brown, 4 Vet. App. 384 (1993). Thus, the Board will proceed with the adjudication of this appeal regarding the claims for VA compensation for a gastrointestinal disorder, a left knee disability, and hypertension. Service connection laws and regulations. The Board has thoroughly reviewed all the evidence in the claims file. Although the Board has an obligation to provide reasons and bases supporting this decision with respect to the matters decided herein, there is no need to discuss, in detail, the evidence submitted by the appellant or on his behalf. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The appellant must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the claimant). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). To establish service connection for a claimed disorder, there must be (1) medical evidence of current disability; (2) medical, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. Hickson v. West, 12 Vet. App. 247, 253 (1999); Degmetich v. Brown, 104 F.3d 1328 (Fed. Cir. 1997); Brammer v. Derwinski, 3 Vet. App. 223 (1992). The requirement of the existence of a current disability is satisfied when a veteran has a disability at the time he files his claim for service connection or during the pendency of that claim. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Service connection involves many factors, but basically means that the facts, shown by the evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service, or if pre-existing such service, was aggravated therein. This may be accomplished by affirmatively showing inception or aggravation during service or through the application of statutory presumptions. 38 C.F.R. § 3.303(a) (2012). With chronic disease shown as such in service so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. This rule does not mean that any documentation of treatment for complaints of gastrointestinal symptoms, left knee pain, or elevated blood pressure during active duty will permit service connection for a chronic gastrointestinal disorder, a chronic left knee disability, and/or hypertension, each first shown as a clear-cut clinical entity, at some later date. For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." When the disease identity is established, there is no requirement of evidentiary showing of continuity. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic, or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b) (2012). The provisions of § 3.303(b), however, only apply to the list of disabilities identified under § 3.309(a) which, as relevant to the issues decided herein, include peptic and duodenal ulcers, arthritis, and essential hypertension. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Otherwise, service connection may be granted for any disease diagnosed after discharge from active duty when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2012). Service connection may also be granted for disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a) (2012). In this regard, the Veteran is presently service connected only for residuals of a right knee fracture with meniscectomy (currently rated 10 percent disabling); urethra stricture, post-urethroplasty and patch graft (currently rated 40 percent disabling); and sexual dysfunction secondary to urethra stricture (currently rated zero percent disabling, but with receipt of an award of special monthly compensation under 38 U.S.C.A. § 1114(k) (West 2002) and 38 C.F.R. § 3.350(a) (2012), for loss of use of a creative organ. Peptic or duodenal ulcers, left knee arthritis (including degenerative disease of the bony joints and cartilage), and hypertension may be presumed to have been incurred in service if each is manifest to a compensable degree within one year after the Veteran's discharge from active duty. 38 C.F.R. §§ 3.307, 3.309 (2012). The Veteran is a Vietnam War Era serviceman. Although his claimed gastrointestinal disorder, left knee disability, and hypertension are not diseases that are presumptively linked to exposure to chemical herbicides (including Agent Orange) for Vietnam War Era veterans, he could conceivably be awarded service connection for these disabilities as due to Agent Orange exposure if there is objective medical evidence linking them to such exposure. See Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). However, to the extent that the Veteran implicitly or overtly asserts a theory of service connection based on in-service Vietnam Era chemical herbicide exposure, such a claim is denied outright by the Board as the Veteran has no presumption of exposure to chemical herbicides during active duty as his service records do not establish that he served within the territorial boundaries of the Republic of Vietnam, or was assigned to perimeter duties at certain airbases in Thailand used by the United States Air Force where chemical herbicides were sprayed, or was attached to specific army units assigned to patrol the De-Militarized Zone (DMZ) between North and South Korea where chemical herbicides were used, or was stationed in Johnston Island in the Pacific where old stockpiles of chemical defoliant were sent for disposal. The Veteran's military records clearly demonstrate that he was never deployed to Vietnam, or otherwise served in any area where chemical herbicides were known to be used. Therefore, he is not presumed to have been exposed to chemical herbicides during active duty and is not entitled to any of the presumptions afforded by the law and regulations for service connection for diseases associated with Vietnam War Era chemical herbicide exposure. (a.) Factual discussion and analysis: Entitlement to service connection for a gastrointestinal disorder, to include a hiatal hernia and duodenal ulcer. In his hearing testimony before the Board and in written statements in support of his claim, the Veteran reported that he was treated for gastrointestinal problems during active duty and contends that he currently has a chronic gastrointestinal disorder including small intestine resectioning surgery that is associated with this clinical history. The Veteran's service medical records show treatment on one occasion in 1980 for an irritable bowel, rule out situational anxiety, and in 1982 for intestinal colic. However, no actual diagnosis of a chronic gastrointestinal disorder was clinically presented during either period of active duty. He separated from his final period of military service in May 1984. Approximately one year afterward, in May 1985, after presenting with complaints of upper gastric pain, he was prescribed medication and scheduled for an upper gastrointestinal (UGI) series to rule out peptic ulcer disease. The May 1986 UGI series provided medical imaging that demonstrated the presence of a small hiatal hernia without reflux and no evidence of peptic ulcer disease. The report of a March 1988 VA examination only noted irritable colon and sliding hiatal hernia by history. Subsequent medical records do not show any active and disabling chronic gastrointestinal disease process. The Veteran's original claim for VA compensation for a chronic gastrointestinal disorder was filed in November 1986 and was denied in a final Board decision dated in February 1993. Thereafter, the entirety of the medical evidence, from 1993 to 2013, shows no further documented diagnosis of a gastrointestinal disorder, chronic or otherwise. The current reopened claim for VA compensation for a chronic gastrointestinal disorder was filed in December 2006. Private, VA, and SSA records, including the report of a May 2012 VA examination, show no current diagnosis of a chronic gastrointestinal disorder. The records reflect that in early 2006, prior to the filing of the claim to reopen, the Veteran underwent surgery for resectioning of part of his small intestine to treat an obstruction of this bowel by a food bezoar. Subsequent records show no diagnosis of a chronic gastrointestinal disorder. VA examination of his intestines in May 2012 noted no active bowel disease (including irritable bowel) was present and that the food bezoar that precipitated the surgical resectioning of the small intestine in 2006 represented a self-inflicted clinical condition that was not related to the one-time diagnosis of irritable bowel in 1980. The Board has considered the evidence discussed above and finds that the objective medical evidence establishes that the Veteran does not have a current diagnosis of a chronic disability of his gastrointestinal system, either now or at any time during the pendency of this current claim. As such, his claim has failed to meet a critical element in the test prescribed by the Court to adjudicate service connection claims. See Hickson v. West, 12 Vet. App. 247, 253 (1999); Degmetich v. Brown, 104 F.3d 1328 (Fed. Cir. 1997); Brammer v. Derwinski, 3 Vet. App. 223 (1992). See also McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). His claim in this regard must therefore be denied as there is no diagnosis of a chronic gastrointestinal disorder manifest at any time during the pendency of this appeal for which VA compensation may be paid. McClain, supra. His claim for VA compensation for a chronic gastrointestinal disorder thus lacks legal merit under the law. See Sabonis v. Brown, 6 Vet. App. 426 (1994). (b.) Factual discussion and analysis: Entitlement to service connection for a left knee disability. As relevant, the Veteran's service medical records show that during active duty in 1975, he accidentally fell and sustained a fracture injury only to his right knee, for which he is now in receipt of VA compensation. No treatment for a left knee injury or any complaints of left knee pain are presented in the medical records pertinent to either period of active service from July 1974 - July 1978 and from January 1980 - May 1984. Post-service medical records show that no supervening left knee injury is indicated in the intervening time period between the Veteran's two periods of active duty, from July 1978 - January 1980. The post-service medical records also do not present any objective clinical finding, verified by X-ray study, of the presence of a degenerative joint disease process affecting the bones and/or cartilage of the Veteran's left knee that was manifest to a compensable degree within the one-year presumptive period for arthritis following his discharge from his second period of active duty in May 1984. Thereafter, no knee complaints are presented in the medical evidence until approximately 15 years later, when a VA treatment note dated in August 1999 shows that the Veteran presented with a complaint (as relevant) of left knee pain whose onset reportedly began approximately 3 - 4 years earlier (i.e., approximately 1995 - 1996). Afterwards, the records show that the Veteran had been involved in a major motor vehicle accident in February 2007 while riding his motorcycle and sustained a fracture injury of his left lower extremity, treatment of which involved surgery for an open reduction and internal fixation of his left knee. In his hearing before the Board in October 2011 and in written statements in support of his claim, the Veteran testified that he injured his left knee in the same accidental fall in service that caused his current right knee disability. The report of a May 2012 VA orthopedic examination shows, in pertinent part, that the examining clinician diagnosed the Veteran with left knee strain and that in consideration of his medical history as discussed above, this disability was not caused by any diagnosed condition during his periods of active duty (which, by implication, also included the Veteran's service-connected right knee disability). The stated rationale was that as a matter of obvious chronology, the Veteran had no objective clinical documentation of left knee pain until 1999, and that he thereafter sustained a supervening left knee injury in 2007 from a motor vehicle accident. The Board has considered the foregoing evidence and finds that the weight of the evidence is against the Veteran's claim for service connection for a left knee disability. Onset of a chronic left knee disability or treatment for left knee symptoms during either period of military service is not demonstrated by the documented medical evidence, and the current left knee disability was not manifest until many years after service. To the extent the Veteran reports a history of onset of a chronic left knee disability in service, manifested by pain after injury to this knee in the same service-related incident that caused his right knee injury, and seeks to establish chronicity of his current left knee strain with service through his self-reported history, the Board finds his account in this regard is not credible as it is contradicted by the objective documented service medical records, which show no such onset or involvement of his left knee in the injurious episode that caused his right knee disability. Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). In view of the foregoing discussion, the Veteran's claim for VA compensation for a left knee disability based on theories of direct causation, or presumptive service-connection, must be denied. Because the evidence in this case is not approximately balanced with respect to the merits of this specific claim, the benefit-of-the-doubt doctrine is not for application. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). (c.) Factual discussion and analysis: Entitlement to service connection for hypertension, to include as secondary to a service-connected disability. As relevant, the Veteran's service medical records show no diagnosis of hypertension during either period of active duty, nor do they show any sustained elevated blood pressure readings that would indicate onset of hypertensive vascular disease in service. Post-service medical records show no diagnosis of hypertension manifest to a compensable degree within one year following the Veteran's separation from his second period of active duty in May 1984. Thereafter, the records reflect that during treatment in March 2002 for an umbilical hernia repair, a surgery pre-operative preparatory note reflects that the Veteran's systolic pressure was elevated at above 140 millimeters of mercury (mm/Hg), although he denied having any history of hypertension. Thereafter, the medical records show that his earliest definitive diagnosis of hypertension was established in 2003, nearly 20 years following his separation from his final period of active duty. VA examination in May 2012 shows, in pertinent part, that the examining clinician diagnosed the Veteran with hypertension and that in consideration of his medical history as discussed above, his hypertension was not caused by any diagnosed condition during his periods of active duty (which, by implication, also included the Veteran's service-connected genitourinary and orthopedic disabilities). The stated rationale was that as a matter of obvious chronology, the Veteran had no objective clinical documentation of hypertension until 2003, nearly two decades after he was separated from his last period of military service. The Board has considered the foregoing evidence and finds that the weight of the evidence is against the Veteran's claim for service connection for hypertension. No onset of hypertensive vascular disease or notations of sustained elevated blood pressure readings at or above 140 mm/Hg systolic or 90 mm/Hg diastolic indicating essential hypertension during either period of military service are shown in the documented medical evidence and the current hypertension was not manifest until many years after service. Therefore, in view of the foregoing discussion, the Veteran's claim for VA compensation for hypertension based on theories of direct causation, presumptive service-connection, or proximate causation by a service-connected disability must be denied. Because the evidence in this case is not approximately balanced with respect to the merits of this specific claim, the benefit-of-the-doubt doctrine is not for application. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). (d.) Other considerations. To the extent that the Veteran asserts that he has, or has had an active diagnosis of a gastrointestinal disorder during the pendency of the claim, and attempts to relate this claimed gastrointestinal disorder as well as his left knee disability and hypertension to his periods of military service or to his service-connected disabilities based on his own personal knowledge of medicine and his familiarity with his individual medical history, the Board first notes that he is not shown in the record to be a trained medical clinician. His military records reflect that he served on active duty in the United States Air Force in the capacity of an aviation fuel specialist and a security specialist. His current records reflect that he has a 12-grade education and his post-service vocational background was in the security industry up until he stopped working. Although lay persons may be competent to provide opinions as to some medical issues (see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011)), as the specific questions in this case regarding the clinical existence and the nature and medical etiology of his claimed gastrointestinal disorder and his left knee disability and hypertension fall outside the realm of common knowledge of a lay person, the Veteran lacks the competence to present a valid medical diagnosis and provide a probative medical opinion linking his claimed disabilities to his periods of military service or to his service-connected disabilities. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (lay persons are not competent to diagnose internal medical conditions, such as a gastrointestinal disorder, degenerative joint disease of the left knee, and hypertension, which may be presented only by a trained physician or medical specialist in gastroenterology, orthopedics, and/or cardiovascular medicine.) His statements and assertions in this regard, absent any supportive objective medical evidence, are thusly not entitled to any probative weight. ORDER Service connection for a gastrointestinal disorder, to include a hiatal hernia and duodenal ulcer, is denied. Service connection for a left knee disability is denied. Service connection for hypertension, to include as secondary to a service-connected disability, is denied. REMAND The Board must make a factual determination as to the adequacy of medical examinations authorized by VA through Board remands. See Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). In March 2012, the Board remanded, inter alia, the issue of entitlement to service connection for a bilateral foot disability for a medical examination to obtain a nexus opinion in the context of the Veteran's relevant clinical history. The requested podiatric examination was performed in May 2012, the report of which indicates that the Veteran had a congenital bilateral pes planus condition that pre-existed his entry into his first period of active duty in July 1974. However, in addressing the crucial question of whether the pre-existing condition was aggravated (i.e., permanently worsened beyond its natural progression) by military service, the opinion addressed this question in language that was both confusing and grammatically unclear. The key portion of the opinion in question stated - The veteran's pes planus is most likely pre-existing prior to his active duty in 1974 or aggravated by his active duty. It cannot be determined with certainty whether this opinion states that the Veteran's pre-existing bilateral pes planus was or was not aggravated by military service and the subsequent discussion and rationale did not otherwise provide any definitive clarification that could have resolved the ambiguities raised by the uncertain language of the opinion. To resolve these ambiguities, the matter should be remanded to the RO/AMC for a clarifying addendum opinion that expressly states whether or not the Veteran's pes planus that pre-existed service was, in fact, aggravated (which is to say permanently worsened beyond its natural progression) by the physical rigors of his active military service and a detailed rationale supporting this determination. This addendum should, to the extent possible, be presented by the same clinician who made the May 2012 nexus opinion now deemed by the Board to be inadequate in its present state for adjudication purposes. Pursuant to the March 2012 Board remand, the Veteran was also provided with a VA psychiatric examination to determine his current Axis I diagnoses and present a nexus opinion regarding these diagnoses and their relationship to his periods of military service, including his service-connected genitourinary and orthopedic disabilities. As relevant, the March 2012 VA psychiatric examiner determined that the Veteran did not have a valid Axis I diagnosis of any psychiatric disability at the time of the examination. Therefore, no nexus opinion was presented. The Board has reviewed the claims file, however, and notes that the current claim for VA compensation for a psychiatric disability has been pending since the date it was filed in April 2003. Although there is evidently no current Axis I psychiatric diagnosis at the present time, the clinical evidence of record includes the report of an October 2003 SSA-authorized psychiatric examination, which presents Axis I diagnoses of recurrent major depressive disorder and dysthymic disorder. VA clinical records contemporaneous to this period also reflect that the Veteran had been prescribed psychotropic medication. This indicates that there was an active psychiatric disorder that was clinically present during the pendency of the Veteran's claim. A review of the Veteran's service medical records also indicates clinical findings of anxiety during active duty. In a service connection claim the required element of the existence of a current disability is satisfied when the claimant has a disability at the time he files his claim for service connection or during the pendency of that claim. In a case such as this one, where the claimed psychiatric disability resolves during the pendency of the claim, VA must make consideration of whether the Veteran is still entitled to compensation benefits for that period during which the claimed disability was extent. VA compensation may be paid for that period in which it was extent if service connection is warranted. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). As the May 2012 examination report does not address this question, it is inadequate for VA adjudication purposes. The claim for VA compensation for a psychiatric disorder is remanded to the RO/AMC so that an addendum opinion can be obtained that addresses the likelihood, in view of the Veteran's relevant clinical history, that the Axis I diagnoses presented in the record during the early part of the pendency of this claim were related to military service on either a direct basis or as secondary to his service-connected genitourinary and orthopedic disabilities, notwithstanding the apparent non-existence of a current Axis I psychiatric diagnosis, per the findings of the May 2012 VA psychiatric examination. Accordingly, the case is REMANDED to the RO/AMC for the following actions: 1. Per a review of the Virtual VA electronic information database, the VA clinical evidence of record is current up to March 2013. The RO should provide the Veteran with the opportunity to submit additional evidence in support of his claims for VA compensation for a bilateral foot disability and psychiatric disorder, or otherwise identify relevant podiatric and psychiatric treatment sources, both private and VA. After obtaining the appropriate waivers, the RO should attempt to obtain copies of any such records not already associated with the Veteran's claims file. If the RO cannot obtain records identified as relevant by the Veteran, a notation to that effect should be inserted in the file. The Veteran is to be notified of unsuccessful efforts in this regard. 2. After the foregoing development requested above has been accomplished, the Veteran's claims file should be made available to the appropriate medical clinician, preferably the one who conducted the May 2012 VA foot examination of record. The Veteran's claims file should be reviewed by the examiner and he/she must state in his/her report that the Veteran's claims file was reviewed. Thereafter, the reviewing clinician should provide a clarifying addendum to the May 2012 nexus opinion, presented in the context of the medical record, with complete supportive rationales, addressing the following: In view of the ambiguity of the language of the following opinion - "The veteran's pes planus is most likely pre-existing prior to his active duty in 1974 or aggravated by his active duty." the reviewing clinician shall present a clarifying addendum opinion with respect to the above that expressly states whether or not the Veteran's pes planus that pre-existed service was, in fact, aggravated (which is to say permanently worsened beyond its natural progression) by the physical rigors of his active military service. The opinion should be presented in clear and unambiguous language. In providing the requested clarifying addendum opinion, the clinician must consider and reconcile any additional opinions and diagnoses of record or any contradictory evidence regarding the above. A rationale for the requested opinion shall be provided. If the clinician cannot provide an opinion without resorting to mere speculation, he/she shall provide a complete explanation stating why this is so. In so doing, the clinician shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he /she has exhausted the limits of current medical knowledge in providing an answer to the particular question. 3. Also, after the foregoing development requested above has been accomplished, the Veteran's claims file should be made available to the appropriate psychiatric clinician, preferably the one who conducted the May 2012 VA psychiatric examination of record. The Veteran's claims file should be reviewed by the examiner and he/she must state in his/her report that the Veteran's claims file was reviewed. Thereafter, the reviewing clinician should provide nexus opinions, presented in the context of the medical record, with complete supportive rationales, addressing the following: (a) The clinician shall identify all Axis I psychiatric diagnoses present during the pendency of the current claim for the period commencing on April 2003, as indicated in the clinical record contemporaneous to the time, including VA outpatient treatment reports and the October 2003 report of the SSA-authorized psychiatric examination. (b) The clinician should express an opinion either concurring with the Axis I diagnosis/diagnoses presented during the pendency of the claim, or rejecting the validity of the diagnoses, in part or in whole, discussing in detail why he/she has arrived at this conclusion. The clinician should reconcile the finding that there was no Axis I diagnosis present on VA examination in May 2012 with the Veteran's prior clinical history of psychiatric diagnosis, treatment, and evaluation, including (but not limited to) the October 2003 SSA psychiatric examination report. (c) If the clinician concludes that the Veteran had a valid Axis I diagnosis or diagnoses during the pendency of the claim, he/she should present an opinion as to whether it is at least as likely as not that these Axis I diagnosis/diagnoses had their onset during the Veteran's periods of active duty or is/are otherwise secondarily related to his service-connected genitourinary and/or orthopedic disabilities. In providing the requested clarifying addendum opinion, the clinician must consider and reconcile any additional opinions and diagnoses of record or any contradictory evidence regarding the above. A rationale for all requested opinions shall be provided. If the clinician cannot provide an opinion without resorting to mere speculation, he/she shall provide a complete explanation stating why this is so. In so doing, the clinician shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he /she has exhausted the limits of current medical knowledge in providing an answer to the particular question. 4. After the above addendum nexus opinions have been obtained, the RO shall readjudicate the claims of entitlement to service connection for a bilateral foot disability and for a psychiatric disorder, to include as secondary to a service-connected disability, in consideration of the additional evidence obtained. If the maximum benefit with respect to either claim is not granted, the Veteran should be provided with a supplemental statement of the case and provided with sufficient opportunity to submit additional evidence and/or argument in response before returning the file to the Board for further appellate consideration of the claim(s). The Board intimates no opinion as to the outcome in this case by the action taken herein. 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). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the Court for additional development or other appropriate action must be handled in an expeditious manner. 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ THERESA M. CATINO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs