Citation Nr: 1326537 Decision Date: 08/20/13 Archive Date: 08/26/13 DOCKET NO. 09-35 286 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Whether new and material evidence has been submitted to reopen a claim for service connection for chest pain, claimed as pleurisy. 2. Entitlement to service connection for a disorder manifested by chest pain, to include pleurisy. 3. Entitlement to service connection for heart palpitations. 4. Entitlement to service connection for hypertension. 5. Entitlement to service connection for a bilateral shoulder disorder. REPRESENTATION Appellant represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD M. Zawadzki, Counsel INTRODUCTION The Veteran served on active duty from July 1989 to June 1996, to include service in the Southwest Asia theater of operations during the Persian Gulf War. These matters come before the Board of Veterans' Appeals (Board) on appeal from a January 2009 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas, which denied service connection for pleurisy, heart palpitations, hypertension, and anterior impingement syndrome of the bilateral shoulders. In November 2012, the Board remanded the case to the RO via the Appeals Management Center (AMC) in Washington, DC, for further development. After completing additional development, the AMC continued to deny the claims (as reflected in a June 2013 supplemental statement of the case (SSOC)), and returned the case to the Board. The remand did not include the matter of whether new and material evidence had been submitted to reopen a claim for service connection for chest pain, claimed as pleurisy. As will be discussed below, however, the Veteran previously filed a claim for service connection for chest pain, which was denied in an October 1997 rating decision. He did not appeal the October 1997 denial. In August 2008, he filed a claim of service connection for several disorders, including pleurisy. In Boggs v. Peake, 520 F. 3d 1330 (Fed. Cir. 2008) the United States Court of Appeals for the Federal Circuit (Federal Circuit) held that a claim for one diagnosed disease or injury cannot be prejudiced by a prior claim for a different diagnosed disease or injury. Rather, the two claims must be considered independently. See Ephraim v. Brown, 82 F. 3d 399 (Fed. Cir. 1996). Because the "factual basis" of a claim for service connection is the Veteran's disease or injury, rather than the symptoms of that disease or injury, claims that are based on distinctly and properly diagnosed diseases or injuries must be considered separate and distinct claims. See Boggs v. Peake, 520 F.3d 1330 (Fed. Cir. 2008). In this case, the RO treated the Veteran's August 2008 claim for service connection for pleurisy as a claim for a disorder distinct from his previously claimed chest pain - these disorders are listed as separate items on the rating codesheets associated with the RO's decisions. However, the evidence does not include a diagnosis of pleurisy, but, rather, continued complaints of chest pain. Accordingly, the Veteran is not seeking service connection for a differently diagnosed disease or injury, and new and material evidence is not therefore required to reopen this claim. See Velez v. Shinseki, 23 Vet. App. 199 (2009) (in determining whether new and material evidence is required, the focus of the Board's analysis must be on whether the evidence presented truly amounts to a new claim based on distinctly diagnosed diseases or injuries or whether the evidence substantiates an element of a previously adjudicated matter.). Under 38 U.S.C.A. §§ 5108 and 7104 (West 2002) the Board must address the question of whether new and material evidence has been received to reopen the claim for service connection. That matter goes to the Board's jurisdiction to reach the underlying claim and adjudicate the claim on a de novo basis. See Barnett v. Brown, 83 F. 3d 1380, 1383 (Fed. Cir. 1996). As the Board must first decide whether new and material evidence to reopen the claim has been received, this matter on appeal has been characterized as reflected on the title page. Because the Board presently reopens the claim, consideration of this matter in this light will not prejudice the Veteran. In August 2008, the Veteran filed a claim for service connection for anterior impingement syndrome of the bilateral shoulders. The evidence of record does not include a diagnosis of this specific shoulder disorder, but reflects diagnoses of a right shoulder contusion and bilateral shoulder strain. Accordingly, this claim has been characterized as reflected on the title page. See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (the scope of a disability claim includes any disability that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record). The Board has reviewed the contents of the Veteran's Virtual VA file and found that it contains additional medical evidence that has been considered by the AMC in the most recent SSOC. Therefore, the Board's consideration of this evidence will not result in prejudice to the Veteran. The issues of entitlement to service connection for chest pain, claimed as pleurisy, heart palpitations, and hypertension 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. All notification and development action needed to fairly adjudicate the claims decided here has been accomplished. 2. In an unappealed October 1997 rating decision, the RO denied service connection for chest pain. 3. Evidence associated with the claims file since the October 1997 denial, when considered by itself or in connection with evidence previously assembled, relates to an unestablished fact necessary to substantiate the claim for service connection for chest pain and raises a reasonable possibility of substantiating the claim. 4. The Veteran's shoulder symptoms are shown to be associated with known diagnoses and his bilateral shoulder disorder was not incurred in or aggravated by active service. CONCLUSIONS OF LAW 1. The RO's October 1997 rating decision denying service connection for chest pain is final. 38 U.S.C.A. § 7105(c) (West 2002); 38 C.F.R. §§ 3.104(a), 20.302(a), 20.1103 (2012). 2. As pertinent evidence received since the October 1997 denial is new and material, the criteria for reopening the claim for service connection for chest pain are met. 38 U.S.C.A. §§ 5108, 7105 (West 2002); 38 C.F.R. § 3.156 (2012). 3. The criteria for the establishment of service connection for a bilateral shoulder disorder, to include as due to undiagnosed illness, are not met or approximated. 38 U.S.C.A. §§ 1110, 1117, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.317 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS In this decision, the Board will discuss the relevant law which it is required to apply. This includes statutes enacted by Congress and published in Title 38, United States Code ("38 U.S.C.A."); regulations promulgated by VA under the law and published in the Title 38 of the Code of Federal Regulations ("38 C.F.R.") and the precedential rulings of the Court of Appeals for the Federal Circuit (as noted by citations to "Fed. Cir.") and the Court of Appeals for Veterans Claims (as noted by citations to "Vet. App."). The Board is bound by statute to set forth specifically the issue under appellate consideration and its decision must also include separately stated findings of fact and conclusions of law on all material issues of fact and law presented on the record, and the reasons or bases for those findings and conclusions. See 38 U.S.C.A. § 7104(d); see also 38 C.F.R. § 19.7 (implementing the cited statute); see also Vargas-Gonzalez v. West, 12 Vet. App. 321, 328 (1999); Gilbert v. Derwinski, 1 Vet. App. 49, 56-57 (1990) (the Board's statement of reasons and bases for its findings and conclusions on all material facts and law presented on the record must be sufficient to enable the claimant to understand the precise basis for the Board's decision, as well as to facilitate review of the decision by courts of competent appellate jurisdiction). The Board must also consider and discuss all applicable statutory and regulatory law, as well as the controlling decisions of the appellate courts. Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Given the favorable disposition of the request to reopen the claim for service connection for chest pain, claimed as pleurisy, the Board finds that all notification and development actions needed to fairly adjudicate this claim have been accomplished. Regarding the claim for service connection for a bilateral shoulder disorder, the Veteran's claim for service connection was received in August 2008. The Veteran was provided notice of what evidence was required to substantiate his claim for service connection, and of his and VA's respective duties for obtaining evidence in correspondence dated in November 2008. The claim was reviewed and the January 2009 rating decision was issued. See 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a), Quartuccio v. Principi, 16 Vet. App. 183 (2002), Pelegrini v. Principi, 18 Vet. App. 112 (2004). See also Mayfield v. Nicholson, 19 Vet. App. 103, 110 (2005), reversed on other grounds, 444 F.3d 1328 (Fed. Cir. 2006); Mayfield v. Nicholson (Mayfield II), 20 Vet. App. 537 (2006); Kent v. Nicholson, 20 Vet. App. 1 (2006), Mayfield v. Nicholson (Mayfield III), 499 F.3d 1317 (Fed. Cir. 2007). In Dingess v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) found that the VCAA notice requirements applied to all elements of a claim. Notice as to this matter was provided in the November 2008 letter. The November 2008 notice letter did not specifically provide notice regarding service connection based on undiagnosed illness. Nevertheless, the Board finds that any notice defect did not affect the essential fairness of the adjudication of this aspect of the claim, and did not result in prejudice to the Veteran. See Sanders v. Shinseki, 129 S. Ct. 1696 (2009). The August 2009 statement of the case (SOC) and May 2010 SSOC included the pertinent regulation, 38 C.F.R. § 3.317. Notably, the Veteran has been represented by an accredited representative during his appeal. See Overton v. Nicholson, 20 Vet. App. 427, 438 (2006). The Veteran has clearly had a meaningful opportunity to participate in the adjudication of his claim such that the essential fairness of the adjudication is not affected. The Veteran has been made aware of the information and evidence necessary to substantiate his claim and has been provided opportunities to submit such evidence. A review of the claims file and Virtual VA e-folder shows that VA has conducted reasonable efforts to assist him in obtaining evidence necessary to substantiate his claim during the course of this appeal. His service treatment records, service personnel records, and VA treatment records have been obtained and associated with his claims file and/or Virtual VA e-folder. The Veteran was also provided with VA examinations to evaluate his claimed bilateral shoulder disorder in March and April 2013. The claim for service connection for a bilateral shoulder disorder was remanded in November 2012 in order to obtain additional medical evidence, specifically, VA treatment records dated after December 2010, and to afford the Veteran a VA examination to obtain a medical opinion regarding the etiology of his claimed disability. In a January 2013 letter, the AMC asked the Veteran to complete and return a VA Form 21-4142, Authorization and Consent to Release Information to the Department of Veterans Affairs (VA), for each private physician who had treated him for his claimed disorders. The Veteran has not since returned a release to enable VA to obtain private treatment records. VA treatment records dated from December 2010 to June 2013 were associated with the Virtual VA e-folder. The Veteran underwent VA examinations in March and April 2013. The March 2013 VA examination report includes a medical opinion addressing the etiology of the Veteran's claimed bilateral shoulder disorder, and the April 2013 VA examination report addresses whether the Veteran has symptoms of a bilateral shoulder disorder which are manifestations of an undiagnosed illness related to his service in the Persian Gulf War. Read together, these examination reports are responsive to the questions posed in the November 2012 remand, and include a basis for the examiners' opinions. Thus, these examination reports are factually informed, medically competent and responsive to the Board's inquiry. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007). There was substantial compliance with the Board's remand directives. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). The record reflects that the Veteran has received VA vocational rehabilitation services, as he reported during VA treatment in August 2012 that he was being paid to go to school through VA vocational rehabilitation. While no VA vocational rehabilitation folder is available for the Board's review, some documents pertaining to VA vocational rehabilitation are currently of record, including VA Forms 28-1900, Disabled Veterans Application for Vocational Rehabilitation, dated in April 1998, November 1999, July 2001, and February 2009, and an October 2011 application and voucher for payment from the vocational rehabilitation revolving fund (as well as documents pertaining to this revolving fund loan). Any additional records which may be in a VA vocational rehabilitation file would not be pertinent to the claim for service connection for a bilateral shoulder disorder decided here. Rather, in his most recent application for VA vocational rehabilitation, in February 2009, the Veteran reported that the nature of his disabilities was frostbite of both feet, migraines, and a left knee disability. Thus, the record does not suggest that any additional VA vocational rehabilitation records, if in existence, would relate to the claimed bilateral shoulder disorder, let alone include information pertaining to the etiology of such disorder. A remand to attempt to obtain any additional VA vocational rehabilitation records would only further delay the claim, impose unnecessary additional burdens on adjudication resources, with no benefit flowing to the Veteran, and is, thus, unnecessary. See Soyini v. Derwinski, 1 Vet. App. 540, 56 (1991). The Veteran has not identified any additional, relevant evidence that has not been requested or obtained. The Veteran has been notified of the evidence and information necessary to substantiate his claim, and he has been notified of VA's efforts to assist him. See Quartuccio v. Principi, 16 Vet. App. 183 (2002). As a result of the development that has been undertaken, there is no reasonable possibility that further assistance will aid in substantiating his claim. Application to Reopen VA may reopen and review a claim that has been previously denied if new and material evidence is submitted by or on behalf of a veteran. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156(a) (2012). See also Hodge v. West, 155 F. 3d 1356 (Fed. Cir. 1998). Regarding petitions to reopen filed on or after August 29, 2001, 38 C.F.R. § 3.156(a) defines "new" evidence as evidence not previously submitted to agency decision makers and "material" evidence as evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). Service connection may be established for disability resulting from personal injury or disease contracted in line of duty, or for aggravation of a pre-existing injury suffered or disease contracted in line of duty. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may be granted for any disease diagnosed after discharge from service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In July 1996, the Veteran filed a claim for service connection for chest pain, noting a history of chest pain during service in 1992. In the October 1997 rating decision, the RO denied service connection for chest pain as due to undiagnosed illness. The Veteran was notified of the October 1997 rating decision (which also adjudicated seven other claims) by letter in October 1997. This letter advised the Veteran that his claims for service connection for a left knee condition, residuals of frozen feet, nasal swelling, and headaches had been granted. The letter did not specifically advise the Veteran that his other claims had been denied. A claim for VA benefits, whether formal or informal, remains pending until it is finally adjudicated. See Adams v. Shinseki, 568 F.3d 956, 960 (Fed. Cir. 2009); 38 C.F.R. § 3.160(c)(2012). In Adams, the Federal Circuit stated that, when VA does not expressly act on each of the claims, it is necessary to decide whether the unaddressed claim is still pending or has been implicitly denied. Id. at 958. A claim will also remain pending if VA has failed to notify the claimant of the denial of the claim. Cook v. Principi, 318 F.3d 1334, 1340 (Fed. Cir. 2002) (en banc). It is well established, however, that in certain circumstances, pursuant to the implicit denial doctrine, "a claim for benefits will be deemed to have been denied, and thus finally adjudicated, even if [VA] did not expressly address that claim in its decision." Adams, 568 F.3d at 961. In Deshotel v. Nicholson, 457 F.3d 1258 (Fed. Cir. 2006), the Federal Circuit held that "where the veteran files more than one claim with the RO at the same time, and the RO's decision acts (favorably or unfavorably) on one of the claims but fails to specifically address the other claim, the second claim is deemed denied, and the appeal period begins to run." Id. at 1261. After the decision in Deshotel was issued, the Court interpreted the application of the implicit denial doctrine. In Ingram v. Nicholson, 21 Vet. App. 232 (2007), the Court held that "a reasonably raised claim remains pending until there is either a recognition of the substance of the claim in an RO decision from which a claimant could deduce that the claim was adjudicated or an explicit adjudication of a subsequent 'claim' for the same disability." Id. at 243. In its opinion, the Court emphasized that it rejected a "broad, sweeping reading of Deshotel as supplanting the pending claim doctrine," and stated that a claimant must be able to reasonably deduce from the decision that the claim was denied. Id. at 247. In determining whether a claim has been previously adjudicated, the key question is whether sufficient notice was provided to the Veteran that would allow him to reasonably understand that he would not be awarded benefits for the disability asserted in his pending claim and thus decide for himself whether to accept the decision or seek redress elsewhere. Jones v. Shinseki, 619 F.3d 1368, 1373 (Fed. Cir. 2010); see also Adams, 568 F.3d 956, 965 ("[T]he implicit denial rule is, at bottom, a notice provision."). The key question in the implicit denial inquiry is whether it would be clear to a reasonable person that VA's action that expressly refers to one claim is intended to dispose of others as well. The October 1997 rating decision clearly denied service connection for chest pain. Thus, there is no question as to whether this claim was adjudicated by the RO. While the October 1997 notice letter does not specifically state that a copy of the October 1997 rating decision was being furnished to the Veteran, it is possible that the notice letter served as a cover letter, in which case the accompanying copy of the rating decision would have clearly informed the Veteran that his claim for service connection for chest pain had been denied. However, even if a copy of the rating decision was not included with the October 1997 letter, a reasonable appellant would have known that the October 1997 rating decision was a denial of the service connection claim for chest pain because the Veteran had only filed one claim - his July 1996 claim for service connection for a left knee injury, nose surgery, a cold weather injury of the feet, a right wrist injury, a history of chest pain, and headaches. In August 1997, the Veteran was afforded a VA compensation and pension examination specifically to evaluate his claimed disabilities, including chest pain. The fact that chest pain was not listed among the conditions for which service connection was granted in the October 1997 notice letter would have reasonably advised the Veteran that his claim for service connection for chest pain had been denied. In light of the fact that the July 1996 claim was the Veteran's original claim for compensation after separation from service, a reasonable person would have understood that the other claims filed, which were not listed as granted, including chest pain, were denied. Therefore, the October 1997 notice letter implicitly denied the July 1996 claim for service connection for chest pain. The Veteran did not initiate an appeal of the October 1997 rating decision; the decision is final as to the evidence then of record, and is not subject to revision on the same factual basis. See 38 U.S.C.A. § 7105(b); 38 C.F.R. §§ 3.104, 20.302, 20.1103. In addition, no new and material evidence was received within one year of the October 1997 rating decision. See 38 C.F.R. § 3.156(b). The Veteran sought to reopen his previously denied claim for service connection in August 2008, when he filed his claim for service connection for pleurisy. The provisions of 38 U.S.C.A. § 5108 require a review of all evidence submitted by or on behalf of a claimant since the last final denial on any basis to determine whether a claim must be reopened. See Evans v. Brown, 9 Vet. App. 273, 282-3 (1996). Here, the last final denial of the claim is the October 1997 rating decision. Furthermore, for purposes of the "new and material" analysis, the credibility of the evidence is presumed. Justus v. Principi, 3 Vet. App. 510, 512-513 (1992). The Court has held that the threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is "low." See Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). Furthermore, in determining whether this low threshold is met, VA must not limit its consideration to whether the newly submitted evidence relates specifically to the reason why the claim was last denied, but instead must examine and determine if it could reasonably substantiate the claim were the claim to be reopened, to include by triggering the Secretary's duty to assist. Id. at 118. At the time of the October 1997 rating decision, there was evidence of chest pain in service and an August 1997 VA examination included a diagnosis of chest wall pain, with no evidence of heart disease or lung disease. There was no evidence of a relationship between the Veteran's current chest wall pain and service. Evidence associated with the claims file since the October 1997 rating decision includes a December 2010 treatment record reflecting that the Veteran described chest pain which had recently been evaluated at a private facility. He reported that he had had this type of chest pain on and off for decades - thus, dating back to service. The December 2010 VA treatment record includes the Veteran's report of a continuity of symptomatology of chest pain since service. The Veteran is competent to report a continuity of symptomatology regarding his chest pain since service. Charles v. Principi, 16 Vet. App. 370 (2002). His report is presumed credible for the new and material analysis. Justus, 3 Vet. App. at 512-513. This report of a continuity of symptomatology suggests a link between the Veteran's current complaints regarding chest pain and service. See Duenas v. Principi, 18 Vet. App. 512 (2004). The December 2010 report of a continuity of symptomatology of chest pain since service is new. This evidence is also material in that it specifically relates to unestablished fact necessary to substantiate the claim for service connection, that is, a relationship between current chest pain and service. Considering the Court's holding in Shade, the Board finds that this evidence raises a reasonable possibility of substantiating the claim for service connection for a disorder manifested by chest pain, to include pleurisy. Thus, this claim must be reopened. Therefore, as new and material evidence has been received, the claim for service connection for a disorder manifested by chest pain, to include pleurisy, is reopened. See 38 U.S.C.A. § 5108; 38 C.F.R. § 3.156. Service Connection for a Bilateral Shoulder Disorder The Veteran asserts that he has a bilateral shoulder disorder related to service. As stated above, service connection may be established for disability resulting from personal injury or disease contracted in line of duty, or for aggravation of a pre-existing injury suffered or disease contracted in line of duty. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2012). Service connection may be granted for any disease diagnosed after discharge from service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). A three-element test must be satisfied in order to establish entitlement to service connection. Specifically, the evidence must show (1) the existence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the disease or injury incurred or aggravated during service (the "nexus" requirement). Walker v. Shinseki, 708 F.3d 1331, 1333 (Fed. Cir. 2013) (citing Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004))). Under 38 C.F.R. § 3.303(b), claims for certain chronic diseases-namely those listed in 38 C.F.R. § 3.309(a)-benefit from a somewhat more relaxed evidentiary standard. See Walker, 708 F.3d at 1339 (holding that "[t]he clear purpose of the regulation is to relax the requirements of § 3.303(a) for establishing service connection for certain chronic diseases."). When a chronic disease is established during active service, then subsequent manifestations of the same chronic disease at any later date, however remote, will be entitled to service connection, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). In order to establish the existence of a chronic disease in service, the evidence must show 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." Id. Thus, the mere manifestation during service of potentially relevant symptoms (such as joint pain or abnormal heart action in claims for arthritis or heart disease, for example) does not establish a chronic disease at that time unless the identity of the disease is established and its chronicity may not be legitimately questioned. Id. If chronicity in service is not established, then a showing of continuity of symptoms after discharge is required to support the claim. Id. Not all diseases that may be considered "chronic" from a medical standpoint qualify for the relaxed evidentiary standard under section 3.303(b). Rather, the Federal Circuit held that this subsection only applies to the specific chronic diseases listed in 38 C.F.R. § 3.309(a). Walker, 708 F.3d at 1338. Thus, if the claimant does not have one of the chronic diseases enumerated in section 3.309(a), then the more relaxed continuity-of-symptomatology standard does not apply, and the "nexus" requirement of the three-element test must be met. Id. at 1338-39. There is no evidence that the Veteran has a shoulder disorder which is listed in 38 C.F.R. § 3.309(a). The Veteran served in the Southwest Asia theater of operations during the Persian Gulf War. As a Persian Gulf Veteran, compensation may be established for objective indications of a "qualifying chronic disability" that became manifest during service on active duty in the Armed Forces in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent prior to December 31, 2016 and by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317. A "qualifying chronic disability" includes: undiagnosed illness and or medically unexplained chronic multisymptom illnesses such as chronic fatigue syndrome, fibromyalgia, and functional gastrointestinal disorders (excluding structural gastrointestinal diseases). 38 U.S.C.A. § 1117(a)(2); 38 C.F.R. § 3.317(a)(2)(i). Objective indications of a chronic disability include both "signs," in the medical sense of objective evidence perceptible to an examining physician, and other, non medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(3). Signs or symptoms that may be manifestations of undiagnosed illness or medically unexplained chronic multisymptom illness include, but are not limited to, the following: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurological signs or symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the respiratory system (upper or lower); (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; (12) abnormal weight loss; and (13) menstrual disorders. 38 C.F.R. § 3.317(b). Disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six month period will be considered chronic. The six month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. 38 C.F.R. § 3.317(a)(4). The determination as to whether the requirements for service connection are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). The Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The evaluation of evidence generally involves a 3-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. The Board must then determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007) (observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). The third step of the inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. Layno v. Brown, 6 Vet. App. 465 (1994). Lay evidence may be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition (i.e., when the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer); (2) the layperson is reporting a contemporaneous medical diagnosis, or; (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009) (where widow seeking service connection for cause of death of her husband, the Veteran, the Court holding that medical opinion not required to prove nexus between service-connected mental disorder and drowning which caused Veteran's death). In ascertaining the competency of lay evidence, the Courts have generally held that a layperson is not capable of opining on matters requiring medical knowledge. Routen v. Brown, 10 Vet. App. 183 (1997). In certain instances, however, lay evidence has been found to be competent with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See, e.g., Barr v. Nicholson, 21 Vet. App. 303 (2007) (concerning varicose veins); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (a dislocated shoulder); Charles v. Principi, 16 Vet. App. 370 (2002) (tinnitus); Falzone v. Brown, 8 Vet. App. 398 (1995) (flatfeet). Laypersons have also been found to not be competent to provide evidence in more complex medical situations. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (concerning rheumatic fever). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). After determining the competency and credibility of evidence, the Board must then weigh its probative value. In this function, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 511-512 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table); see Madden v. Brown, 125 F.3d 1447 (Fed Cir. 1997) (holding that the Board has the "authority to discount the weight and probative value of evidence in light of its inherent characteristics in its relationship to other items of evidence"). The standard of proof to be applied in decisions on claims for veterans' benefits is set forth in 38 U.S.C.A. § 5107. A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 C.F.R. § 3.102. When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). Considering the pertinent evidence of record in light of the law, the Board finds that the preponderance of the evidence is against the claim and service connection for a bilateral shoulder disorder is not warranted. Service treatment records are negative for complaints regarding or treatment for the shoulders. In his June 1989 Report of Medical History at enlistment, the Veteran denied a painful or "trick" shoulder. Clinical evaluation of the upper extremities on enlistment examination was normal. In his May 1996 medical assessment at separation, the Veteran reported that he did not suffer from any injury or illness while on active duty for which he did not seek medical care. In a May 1996 Report of Medical History, the Veteran denied having or ever having had a painful or "trick" shoulder. On an undated separation examination, clinical evaluation of the upper extremities was normal. Post-service VA treatment records reflect that, in November 2010, the Veteran reported that he injured his right shoulder a day earlier when he fell on his motorcycle. He described right shoulder pain. X-ray of the right shoulder revealed no fracture or dislocation. The impression was right shoulder pain/contusion and motorcycle crash. Examination during VA treatment in January 2013 revealed left neck/shoulder tenderness to palpation and pain with full rotation to the left. The assessment included left neck strain. The Veteran was afforded a VA examination to evaluate his claimed shoulder disability in March 2013. The examiner stated that the Veteran had a diagnosis of bilateral shoulder strain. In describing the history of this condition, she noted that the Veteran complained of intermittent bilateral shoulder pain, with gradual onset. He denied an acute injury. The examiner observed that medical records indicated a motorcycle accident in November 2010. She stated that, according to these records, X-rays of the right shoulder were negative for fracture or dislocation. The examiner opined that the Veteran's claimed shoulder disorder was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. In providing a rationale for this opinion, she stated that, there were no medical records to support a diagnosis of a shoulder disorder occurring while the Veteran was in the military. She added that there were no medical records to support a claim that a shoulder condition was aggravated by any active duty service; rather, the only medical records referring to shoulder pain were dated in 2010 and the Veteran was discharged in 1996. The Veteran underwent a VA Gulf War examination to evaluate this aspect of his claim in April 2013. The examiner commented that, according to the publication "Gulf War and Health", there was sufficient evidence of a causal relationship with PTSD and there was sufficient evidence of an association between gastrointestinal symptoms consistent with functional gastrointestinal disorders such as irritable bowel syndrome (IBS), multi-system illness, and other psychiatric disorders. He stated that chronic disability patterns associated with the Southwest Asia environmental hazards had two distinct outcomes: an undiagnosed illness and a diagnosed medically unexplained chronic multisymptom illness, including chronic fatigue syndrome, fibromyalgia, and IBS. The examiner opined that the Veteran did not exhibit a disability pattern consistent with the concept of an undiagnosed illness as there was no historical or documentary evidence supporting this contention. Rather, his symptomatology could be explained based on standard medical definitions and practices. He added that the Veteran also did not have a diagnosable but medically unexplained chronic multi-symptom illness of unknown etiology. The Veteran does have qualifying service in Southwest Asia during the Persian Gulf War; however, his shoulder symptoms have been associated with various diagnosed disorders, including a right shoulder contusion, left neck strain, and bilateral shoulder strain. His shoulder symptoms have not been identified as signs or manifestations of an undiagnosed illness or medically unexplained chronic multisymptom illness associated with his Persian Gulf War service. Rather, the April 2013 VA examiner examined the Veteran, reviewed the record, and specifically opined that the Veteran did not exhibit disability pattern consistent with the concept of an undiagnosed illness; instead, his symptomatology could be explained based on standard medical definitions and practices. This same examiner also clearly stated that the Veteran did not have a diagnosable but medically unexplained chronic multisymptom illness of unknown etiology. Therefore, the Veteran's current shoulder complaints do not represent objective indications of a "qualifying chronic disability" related to his Persian Gulf War service and presumptive service connection under 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317 is not warranted. Service connection for a bilateral shoulder disorder is also not warranted on a direct basis. The March 2013 VA examination report reflects a diagnosis of bilateral shoulder strain. Thus, the first element of the service connection claim is satisfied. However, there is no competent and credible evidence linking the Veteran's current bilateral shoulder disorder to service. Service treatment records are negative for any complaints or findings of a shoulder disorder. During the March 2013 VA examination, the Veteran reported a gradual onset of shoulder pain. The Veteran is competent to describe symptoms such as pain. See, e.g., Layno v. Brown, 6 Vet. App. 465 (1994). He did not assert that this gradual onset of shoulder pain began during service. In his September 2009 VA Form 9, the Veteran stated that none of his symptoms affected him until the Persian Gulf War. Liberally construing the Veteran's statements, taken together with his assertion that his current bilateral shoulder disorder is related to service, as indicating that the gradual onset of his shoulder disorder was during military service, this assertion would be outweighed by the May 1996 Report of Medical Assessment at separation. Significantly, the Veteran reported during his May 1996 medical assessment that he did not have any injury or illness while on active duty for which he did not seek medical care - therefore indicating that he did not have any injury or illness related to his shoulders. He specifically denied having or ever having had a painful or "trick" shoulder in his May 1996 Report of Medical History and, on separation examination, clinical evaluation of the upper extremities was normal. The medical assessment at separation is highly probative, because it was generated with a view towards ascertaining the Veteran's then-state of physical fitness and is akin to statements of diagnosis or treatment. Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (observing that although formal rules of evidence do not apply before the Board, recourse to the Federal Rules of Evidence may be appropriate if it assists in the articulation of the reasons for the Board's decision); see also LILLY'S: AN INTRODUCTION TO THE LAW OF EVIDENCE, 2nd Ed. (1987), pp. 245-46 (many state jurisdictions, including the federal judiciary and Federal Rule 803(4), expand the hearsay exception for physical conditions to include statements of past physical condition on the rationale that statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy since the declarant has a strong motive to tell the truth in order to receive proper care); see also Curry v. Brown, 7 Vet. App. 59, 68 (1994) (holding that contemporaneous evidence has greater probative value than subsequently reported history). Service connection may be granted for any disease diagnosed after discharge from service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. See 38 C.F.R. § 3.303(d). The relationship between the current shoulder disorder and service, however, must be established by evidence of a nexus. See Walker, 708 F. 3d at 1338. The March 2013 VA examiner opined that the Veteran's claimed bilateral shoulder disorder was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The March 2013 VA examiner's opinion is highly probative regarding the relationship between the Veteran's current bilateral shoulder disorder and service. See Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) (it is the responsibility of the Board to assess the credibility and weight to be given the evidence) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)). See also Guerrieri, 4 Vet. App. at 470- 71 (the probative value of medical evidence is based on the physician's knowledge and skill in analyzing the data, and the medical conclusion he reaches; as is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board). The examiner formed her opinion after interview with and examination of the Veteran as well as review of the claims file. Her opinion was also supported by a clearly-stated rationale. Specifically, she stated that there were no medical records to support a diagnosis of a shoulder condition occurring while the Veteran was in the military and there were no medical records to support a claim that the shoulder disorder was aggravated by active duty service. Rather, the only medical records referring to shoulder pain were dated in 2010 and the Veteran was discharged in 1996. While this opinion was based, in part, on the absence of a diagnosis of a shoulder disorder during service, as indicated above, any reports of a bilateral shoulder disorder in service are found not credible in light of the more probative contemporaneous medical records from May 1996. The March 2013 VA examiner did not address the January 2013 VA treatment record documenting left neck/shoulder tenderness to palpation and pain with full rotation to the left. However, no assessment particular to the left shoulder was rendered by the VA physician; rather, the pertinent assessment was left neck strain. Thus, failure to address the January 2013 VA treatment record does not render the March 2013 opinion inadequate. See Barr, 21 Vet. App. at 311. The Veteran has not presented or identified any existing, contrary medical opinion that, in fact, supports the claim for service connection on a direct basis. Thus, the only competent, probative (persuasive) medical opinion evidence regarding the relationship between the Veteran's current bilateral shoulder disorder and service weighs against the claim for service connection. In addition to the medical evidence, the Board has considered the Veteran's contention that he has a current bilateral shoulder disorder related to service, to include his service in the Southwest Asia theater of operations during the Persian Gulf War. 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, such as concerning a form of cancer. See also Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (discussing this axiom in a claim for rheumatic fever); Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed. Cir. 2010) (recognizing that in some cases lay testimony "falls short" in proving an issue that requires expert medical knowledge); Waters v. Shinseki, 601 F.3d 1274, 1278 (Fed. Cir. 2010) (concluding that a Veteran's lay belief that his schizophrenia had aggravated his diabetes and hypertension was not of sufficient weight to trigger VA's duty to seek a medical opinion on the issue). The Veteran does not have or claim to have any specialized knowledge in the field of medicine. The etiology of his current bilateral shoulder disorder, and the question of whether his symptoms may be objective manifestations of an undiagnosed illness or a chronic multisymptom illness, are therefore beyond his competence. Moreover, these questions are complex in nature. Therefore, to the extent he has asserted that he has a bilateral shoulder related to service, to include his service in the Southwest Asia theater of operations during the Persian Gulf War, the Board finds such assertions to be of little probative value, especially in relation to the March 2013 and April 2013 VA examiners' opinions, as the Veteran is not competent to opine on these complex medical questions. His contentions are outweighed by the medical evidence of record, specifically the opinions of the March 2013 and April 2013 VA examiners. For all the foregoing reasons, the claim for service connection for a bilateral shoulder disorder is denied. In arriving at this decision, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER New and material evidence having been received; the issue of entitlement to service connection for a disorder manifested by chest pain, to include pleurisy, is reopened. Service connection for a bilateral shoulder disorder is denied. REMAND The Veteran was afforded VA examinations to obtain medical opinions regarding his claims for service connection for pleurisy, heart palpitations, and hypertension in March and April 2013. However, the opinions provided in regard to the claims for service connection for heart palpitations and hypertension were each based on an inaccurate factual premise and the opinion regarding the claim for service connection for pleurisy, to include as due to undiagnosed illness, is confusing. Therefore, supplemental medical opinions are necessary. As the claims are being remanded, the Veteran should be provided additional VCAA notice regarding the Persian Gulf War aspect of his claims. Accordingly, the case is REMANDED for the following action: 1. Provide the Veteran a corrective VCAA notice under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b), that advises him of the information and evidence necessary to substantiate his claims for service connection for a disorder manifested by chest pain, to include pleurisy, heart palpitations, and hypertension, to include as due to an undiagnosed illness or other qualifying chronic disability, pursuant to 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317. 2. Request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for his chest pain, heart palpitations, and hypertension. After acquiring this information and obtaining any necessary authorization, obtain and associate any outstanding pertinent records with the claims file or Virtual VA e-folder. A specific request should be made for: (1) records regarding emergency room treatment for chest pain at Charleston Methodist, dated in July 2008 (as identified during VA treatment in July 2008); (2) records regarding treatment for chest pain from Methodist Hospital, dated in November 2010 (to include any records available in the Veterans Health Information Systems and Technology Architecture (VISTA); and (3) records from the North Texas Veterans Health Care System, dated since June 2013. If any identified records are not obtainable (or none exist), the Veteran and his representative should be notified and the record clearly documented. 3. Associate with the claims file the Veteran's VA vocational rehabilitation folder. 4. After all available records have been associated with the claims file, forward the claims file to either the physician that conducted the March 2013 VA examinations, or the April 2013 VA examination, if available, for a supplemental medical opinion. The claims folder must be made available to the examiner for review of the case. A notation to the effect that this record review took place should be included in the report of the examiner. The purpose of these additional opinions is to ascertain whether the Veteran has a disorder manifested by chest pain, heart palpitations, or hypertension, related to service, or which is a manifestation of an undiagnosed illness or other qualifying chronic disability relating to his Persian Gulf War service. As indicated above, the examiner should review the record in conjunction with rendering the requested opinion; however, in regard to the claim for service connection for a disorder manifested by chest pain, to include pleurisy, and the claim for service connection for heart palpitations, his or her attention is drawn to the following: * In a June 1989 report of medical history the Veteran denied pain or pressure in the chest. * A June 1989 enlistment examination reflects a normal chest and heart. * In February 1990 the Veteran complained of left-sided chest pain and left upper abdominal pain. Chest X-ray was normal. The assessment was acute gastritis. * The Veteran complained of mild chest pain in May 1990, after having smoked crack cocaine. Lungs were clear to auscultation. Electrocardiogram (EKG) revealed normal sinus rhythm with no signs of ischemia. The assessment was crack cocaine abuse by history, normal examination. * In July 1990 the Veteran complained of radiant pain to the midsternal region of the chest for six months and examination revealed pain with palpation of the costochondral margin. The impression was costochondritis, rule out gastritis. [While the Board previously reported that this treatment note indicated that the Veteran had heart palpitations on examination, careful review of the record does not reveal a finding of palpitations; rather, the Veteran had pain with palpation of the costochondral margin.] * An August 1990 service treatment record reflects complaints of chest pain and a heart murmur. Chest X-ray was normal. The assessment was thoracic and abdominal pain, questionable etiology. * In a May 1991 Report of Medical History the Veteran denied pain or pressure in the chest and palpitation or pounding heart. The Physician Assistant, Certified (PA-C) commented that the Veteran reported a history of high blood pressure, although he was not on any medication and blood pressure was normal on examination. * In September 1991, the Veteran presented for treatment for a cold, and described chest pain when coughing. * In May 1992 the Veteran reported occasional sharp pain in his heart for a period of one month. The examiner noted that the Veteran had a history of occasional sharp chest pains on the left which were not reproducible, were non-exertional, and only lasted one to two seconds. The Veteran reported that these pains were usually associated with deep breathing, and occurred several times a week. The assessment is difficult to decipher, but appears to indicate muscle pain. * In June 1992 the Veteran complained of "frequent heart aches" and examination revealed no heart murmur. There was point tenderness at the left side of the chest wall at the 7th rib. The assessment was costochondritis on the left and the examiner commented that the Veteran was low risk for heart disease. * In January 1993, the Veteran reported chest problems for 10 years. * Lungs and chest and heart were normal on periodic examination in February 1993. * In his May 1996 Report of Medical History the Veteran denied pain or pressure in the chest, palpitation or pounding heart, or high or low blood pressure. * In a May 1996 Report of Medical Assessment at separation, the Veteran denied suffering from any illness or injury on active duty for which he did not seek medical attention. * An undated separation examination shows normal lungs and chest and heart. * Service treatment records include normal chest x-rays dated in February 1990, August 1990, February 1993, October 1994, and May 1996; * On VA general medical examination in August 1997, the Veteran described several episodes of left chest pain, lasting only a few seconds, not associated with exercise, but associated with a change in body position. He reported that he had been checked out and did not have any heart disease or high blood pressure. He denied any history of heart disease or high blood pressure whatsoever. The diagnosis was "[c]hest wall pain, no evidence of heart disease or lung disease." * August 1997 chest X-ray revealed the cardiomediastinal silhouette and hila to be within normal limits. The lung and pleural spaces were clear and the bony thorax appeared normal. EKG revealed sinus bradycardia and sinus arrhythmia with early repolarization, but was otherwise a normal EKG. * During VA treatment in December 2001 the Veteran complained of sharp, left-sided chest pain when trying to pull up his pants. * During VA treatment in October 2004 the Veteran reported occasional pleuritic chest pain which occurred once every two months and resolved within five to ten seconds. * At the emergency department of the Dallas VAMC in February 2007, the Veteran reported that his chest wall was sore from coughing. The assessment was upper respiratory infection. * At the emergency department of the Dallas VAMC in January 2008, the Veteran reported chest pain off and on for two weeks, with associated shortness of breath and weakness. In another note from the same day, the Veteran reported intermittent, sharp, left-sided chest pain for two days which he attributed to stress. He stated that his chest pain came on with movement and deep breaths and lasted for a few seconds. Chest X-ray revealed no evidence of active infiltrate, pneumothorax, or effusion. Heart and mediastinal structures were unremarkable. The pertinent impression was left chest wall pain. * In July 2008, the Veteran presented to the emergency department of the Dallas VAMC with a complaint of anterior chest pain radiating to his back and left shoulder which was aggravated by deep inspiration. He reported having these symptoms worked up in the emergency department in the past, with a diagnosis of chest wall pain. He commented that he experienced similar symptoms when under stress and stated that he was currently under business stress. The diagnosis was chest wall versus pleuritic chest pain and sleep deprivation, rule out depression. * During VA treatment in December 2009, the Veteran reported shortness of breath but denied chest pain. The assessment was shortness of breath of unclear etiology. * During VA treatment in August 2010 the Veteran complained of shortness of breath with no associated chest pain. The pertinent assessment was shortness of breath. The physician commented that this could be due to underlying mild emphysema given the Veteran's history of smoking and the obstructive pattern seen on pulmonary function tests (PFTs) in April 2010. There was a low level of suspicion for pulmonary malignancy. Examination on this date also revealed pulse of 102 and assessment included tachycardia and holosystolic murmur noted on examination. * During VA mental health treatment in October 2010 the Veteran described having a "fast heart" at times during the day, in addition to his arms shaking. * During VA treatment in December 2010, the Veteran reported that he had been evaluated for chest pain at a private facility, where he had had cardiac catheterization and was told that he had minor blockages. He denied further episodes of chest pain since that incident, but stated that he had had this type of chest pain on and off for decades. He added that he had never been told he had a heart attack. Chest X-ray was negative and the assessment included chest pain, likely angina. * In April 2011, the Veteran reported to his VA physician that he had chest pain which occurred without exertion. The physician commented that it sounded as if the Veteran might have occasional palpitations. The assessment included exertional fatigue/presyncope, need to rule out arrhythmia. The Veteran was referred for an event monitor. * In May 2011, the Veteran was seen in the VA primary care clinic with a complaint of exertional dyspnea and chest pain. The assessment was chest pain and dyspnea and the physician opined that the etiology was entirely unclear, although the chest pain was "assuredly NOT ischemic given clean cath." He added that there was no obstructive lung disease and the pain was not musculoskeletal in description, but could be an element of vasospasm, noting that the Veteran had a remote history of cocaine use, although he denied current use. * The Veteran was afforded a VA respiratory examination in March 2013. The examiner indicated that the Veteran had not, nor had he ever been, diagnosed with a respiratory condition. The Veteran gave a history of intermittent pain with breathing. The examiner opined that there was no objective evidence to support pleurisy. She acknowledged that the Veteran reported frequent episodes of "pleuritic pain" which made it hard for him to work, but that, on examination, lungs were clear in all fields with no wheeze or rales. * The Veteran underwent VA heart examination on the same day. The examiner indicated that the Veteran had not, nor had he ever been, diagnosed with a heart condition. The Veteran gave a history of first experiencing heart palpitations in 1990 or 1991, which lasted for about a week, then resolved. He added that he subsequently had episodes of palpitations every two to three months since. The examiner checked boxes indicating both yes and no as to whether the Veteran had a cardiac arrhythmia, and noted that the Veteran reported that he had had abnormal EKGs in the past and reported that he had had arrhythmia. The examiner stated that there were no medical records to support this assertion. The examiner remarked that echocardiogram indicated normal cardiac size and function and there was no objective data in the Veteran's medical records or on examination to support any cardiac etiology for his complaints of ongoing palpitations or chest pain. * The March 2013 VA examiner opined that the Veteran's claimed pleurisy and palpitations were less likely than not incurred in or caused by the claimed in-service injury, event, or illness. In providing a rationale for this opinion, she stated that there was no objective evidence to support a diagnosis of pleurisy. She commented that the Veteran was evaluated for numerous episodes of chest pain during service, and received a diagnosis of palpitations in July 1990; however, no subsequent evaluations confirmed this diagnosis and he did not appear to have any documented episodes of any arrhythmia. She added that his heart rate also did not appear to be elevated at any of his evaluations or clinic visits and there did not appear to be sufficient evidence to support a current diagnosis of palpitations. * The Veteran underwent VA Gulf War examination in April 2013, and the examiner opined that that the Veteran did not exhibit a disability pattern consistent with the concept of an undiagnosed illness as there was no historical or documentary evidence supporting this contention. Rather, his symptomatology could be explained based on standard medical definitions and practices. He added that the Veteran also did not have a diagnosable but medically unexplained chronic multisymptom illness of unknown etiology. After a review of the entire evidence of record, the examiner must answer the following questions: * Are the Veteran's reports of chest pain and/or heart palpitations attributed to any known clinical diagnosis? If so, what is that diagnosis? If not, do these symptoms represent an objective indication of chronic disability resulting from an undiagnosed illness or a medically unexplained chronic multisymptom illness related to the Veteran's Persian Gulf War service? * If the Veteran's reports of chest pain and/or heart palpitations ARE attributed to any known clinical diagnosis, is that diagnosed disorder related to any incident of service? In rendering the requested opinion, the examiner is advised that the Veteran is competent to report symptoms such as chest pain and heart palpitations. The examiner MUST specifically consider and address the Veteran's December 2010 report of chest pain on and off for decades. He or she must also specifically consider and address the August 1997 EKG revealing sinus bradycardia and sinus arrhythmia and the August 2010 VA treatment note revealing pulse of 102 with an assessment of tachycardia. In regard to the claim for service connection for hypertension, the examiner's attention is drawn to the following: * In his June 1989 Report of Medical History at enlistment, the Veteran denied high or low blood pressure. Blood pressure was 110/66 on enlistment examination and clinical evaluation of the heart was normal. * Service treatment records document several elevated blood pressure readings. Specifically, blood pressure was 120/92 in January 1991, 130/90 in September 1991, 150/98 in August 1992, 130/90 in October 1992, 130/98 in June 1994, 136/96 in October 1994, and 136/92 on an undated separation examination. * Other blood pressure readings in service were normotensive. For example, blood pressure was 118/80 in October 1989; 100/78 in November 1989; 138/80 in February 1990; 150/80 in May 1990; 116/64 in July 1990; 120/60 in August 1990; 126/78 in December 1991; 130/78 in May 1992; 120/58 in June 1992; 128/68 and 140/67 in July 1992; 124/80, 132/68, and 124/80 in August 1992 (the day of and the two days after the blood pressure reading of 150/98 noted above); 122/80 in October 1992; 130/70 in November 1992; 150/80 in January 1993; 122/78 and 138/70 in February 1993; 124/70, 130/80, and 130/70 in March 1993; 110/70 in October 1993; 130/68 in January 1992; 125/73 in February 1994; 110/70 in March 1994; 140/80 in April 1994; 118/82 in June 1994 (the day before the blood pressure reading of 130/98); 110/60 in July 1994; 110/70 and 124/64 in September 1994; 132/74 in January 1995. * On VA general medical examination in August 1997, the Veteran reported that he did not have any heart disease or high blood pressure. He denied any history of heart disease or high blood pressure whatsoever. Blood pressure on examination was 110/70. * On VA general medical examination in July 2001, the Veteran's blood pressure readings were recorded as 130/80 while sitting and 130/88 and 130/85 while supine. * Various post-service VA treatment records reflect normotensive blood pressure readings. Specifically, blood pressure was 118/70 in March and November 2000; 130/70 in November 2001; 125/80 in December 2002; 137/77 in March 2004; and 151/89 in October 2004. * During VA treatment in October 2004, the Veteran was started on hydrochlorothiazide (HCTZ) for hypertension. Blood pressure on that date was 151/89. * VA treatment records indicate elevated blood pressure readings beginning in December 2004, when the Veteran's blood pressure was recorded as 167/96. * The Veteran underwent VA hypertension examination in March 2013. The examiner stated that the Veteran had been diagnosed with hypertension, but the date of diagnosis was unclear. She noted that the Veteran reported that he was diagnosed with hypertension in 1995 or 1996, but his VA medical records indicated a diagnosis of hypertension in 2004. The examiner reported that the Veteran stated that he was diagnosed with hypertension shortly before discharge from service; however, she stated that his medical records indicated that his elevated blood pressure began in 2004. * The March 2013 VA examiner opined that the Veteran's claimed hypertension was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. In providing a rationale for this opinion, she stated that, from the available medical records, it appeared that the Veteran's hypertension did not begin until 2004 and he was discharged from service in 1996. She added that there is no medical evidence to support a claim that hypertension was aggravated beyond its natural progression by active duty service. After a review of the entire evidence of record, the examiner must answer the following question: * Did the Veteran's current hypertension began during active service or is it related to any incident of service? The examiner MUST specifically consider and address the Veteran's elevated blood pressure readings in service (discussed above), in particular, the blood pressure of 136/92 on separation examination. An explanation MUST be provided for EACH opinion or conclusion expressed. If further examination of the Veteran is deemed necessary, arrange for the Veteran to undergo VA examination to obtain the above-noted opinions. In conjunction with the examination, the claims folder must be made available to the examiner for review of the case. A notation to the effect that this record review took place should be included in the report of the examiner. All indicated tests and studies should be accomplished. All examination findings, along with the complete explanation for all opinions expressed, should be set forth in the examination report. 5. Conduct any other appropriate development deemed necessary. Thereafter, readjudicate the claims, considering all evidence of record. If any benefit sought remains denied the Veteran and his representative should be provided an SSOC. An appropriate period of time should be allowed for a response. The appellant has the right to submit additional evidence and argument on the matters that 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 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). ______________________________________________ Vito A. Clementi Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs