Citation Nr: 1329487 Decision Date: 09/13/13 Archive Date: 09/20/13 DOCKET NO. 08-17 570 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUE Entitlement to service connection for gout/gouty arthritis, to include as secondary to service-connected ischemic heart disease. REPRESENTATION Appellant represented by: Tennessee Department of Veterans' Affairs WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD M. Zawadzki, Counsel INTRODUCTION The Veteran had active military service in the U.S. Army from September 1965 to July 1967. His awards and decorations include the Combat Infantryman's Badge (CIB) and Purple Heart Medal, among others. The Veteran is in receipt of a 100 percent schedular evaluation for ischemic heart disease, effective April 29, 2005, and a separate 100 percent schedular evaluation for PTSD, effective March 2, 2011. The Veteran is also in receipt of special monthly compensation, effective March 2, 2011. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a January 2008 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. In January 2010, the Veteran presented testimony at a Travel Board hearing at the RO before the undersigned Veterans Law Judge. A transcript of that hearing is of record. The Board previously remanded the Veteran's case to the RO via the Appeals Management Center (AMC) in Washington, DC, for further development in March 2010, July 2012, and March 2013. The AMC continued to deny the claim listed on the title page (as reflected in a May 2013 supplemental statement of the case (SSOC)), and returned this matter to the Board. The Veteran's Virtual VA e-folder and contains additional medical evidence that has been considered by the AMC in the most recent SSOC. Therefore, consideration of this evidence will not result in prejudice to the Veteran. As discussed in March 2013, in his June 2007 claim, the Veteran filed a claim for service connection for gout. In the January 2008 rating decision, the RO denied service connection for gout. Nevertheless, given the evidence of record (including findings of arthritis in the hands and feet) in the March 2013 remand, the issue on appeal was characterized as entitlement to service connection for gout and/or arthritis in the hands and/or feet, to include as secondary to service-connected ischemic heart disease. 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 remanded the claim, in part, to obtain a supplemental medical opinion. The Board instructed the VA examiner to provide an opinion as to whether the Veteran had had gout, arthritis in the hands and/or feet, and/or gouty arthritis at any time since June 2007(when he filed his claim for service connection). The examiner responded in March 2013 that the Veteran was diagnosed with gout in 2000, so he had had gouty arthritis since June 2007. See DORLAND'S ILLUSTRATED MEDICAL DICTIONARY (28TH Ed. 1994) at 140 (gouty arthritis is defined as arthritis due to gout). In light of the Veteran's June 2007 claim, the March 2013 medical opinion, and the evidence of record, the issue on appeal has been characterized as reflected on the title page. FINDINGS OF FACT 1. All notification and development action needed to fairly adjudicate the claim decided below has been accomplished. 2. The Veteran's current gout/gouty arthritis, which first manifested more than one year after separation from service, is not attributable to service nor is it proximately due to or aggravated by service-connected ischemic heart disease. CONCLUSION OF LAW The criteria for the establishment of service connection for gout/gouty arthritis, to include as secondary to service- connected ischemic heart disease, are not met or approximated. 38 U.S.C.A. §§ 1110, 1112, 1113, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310(a) (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION 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 provisions of the Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a), and as interpreted by the United States Court of Appeals for Veterans Claims (Court) have been fulfilled. The Veteran's claim for service connection for gout was received in June 2007. The Veteran was provided notice of what evidence was required to substantiate his claim for service connection on a direct basis, and of his and VA's respective duties for obtaining evidence, in correspondence dated in July 2007. A July 2012 VCAA letter advised the Veteran of the information and evidence necessary to substantiate his claim for service connection on both direct and secondary bases, while a March 2013 VCAA letter advised him of the information and evidence necessary to substantiate his claim for service connection on a secondary basis. While the July 2007 and July 2012 VCAA letter addressed the claim for service connection for gout, the March 2013 VCAA letter addressed the expanded claim for service connection for gout and/or arthritis in the hands and/or feet, to include as secondary to service-connected ischemic heart disease. The claim was then reviewed and the May 2013 SSOC was issued. See 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013), 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 Court found that the VCAA notice requirements applied to all elements of a claim. Notice as to this matter was provided in the July 2007, July 2012, and March 2013 letters. 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 and VA and private treatment records have been obtained and associated with his claims file/Virtual VA e-folder. The Veteran was also provided with a VA examination to evaluate his claimed gout in August 2012 and a medical opinion was obtained in March 2013. The claim for service connection for gout was most recently remanded in March 2013 to obtain an additional medical opinion to clearly address whether the Veteran had had gout, arthritis in the hands and/or feet, and/or gouty arthritis at any time since June 2007 (when he filed his claim for service connection); whether any gout, arthritis in the hands and/or feet, and/or gouty arthritis which had been present at any time since June 2007 began during active service or was related to any incident of service; whether any gout, arthritis in the hands and/or feet, and/or gouty arthritis which had been present at any time since June 2007 was proximately due to or the result of or chronically aggravated or worsened by the Veteran's ischemic heart disease; and whether any arthritis in the hands and/or feet, to include gouty arthritis, began within one year of discharge from active service. The claim was also remanded to provide additional VCAA notice in light of the expansion of the claim and to obtain additional VA treatment records. The Board instructed that, if, after completing the requested development, the benefit sought remained denied, the Veteran and his representative should be provided an SSOC which included citation to and discussion of all pertinent laws and regulations, including 38 C.F.R. § 3.310. In March 2013, the AMC obtained a supplemental medical opinion which, as will be discussed in greater detail below, when read in its entirety, is responsive to the questions posed in the March 2013 remand and, therefore, is fully responsive to the Board's remand directives. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007). The Veteran was provided additional VCAA notice in March 2013. While this letter advised him of the information and evidence necessary to substantiate his claim for service connection for gout and/or arthritis in the hands and/or feet on a secondary basis (as opposed to also providing notice regarding the information and evidence necessary to substantiate a claim for service connection on a direct basis) he had previously been informed of the information and evidence necessary to substantiate his claim for service connection on a direct basis in July 2007 and July 2012. Additional VA treatment records, as identified in the March 2013 remand, were obtained and associated with the Virtual VA e-folder. In readjudicating the claim, the AMC did not specifically cite 38 C.F.R. § 3.310, the pertinent regulation regarding secondary service connection. However, in the May 2013 SSOC, the AMC did state that service connection may be granted for a disease or injury which resulted from a service-connected disability or was aggravated thereby. Based on the actions taken by the AMC, there has been substantial compliance with the March 2013 remand. Dyment v. West, 13 Vet. App. 141 (1999) (holding that remand not required under Stegall v. West, 11 Vet. App. 268 (1998) where there was substantial compliance with remand directives). The Veteran is in receipt of Worker's Compensation benefits. While complete records regarding his Worker's Compensation claim have not been obtained, the record reflects that these records pertain to his left shoulder, as opposed to his gout/gouty arthritis. A remand to obtain these records would therefore only cause further delay, impose unnecessary additional burdens on adjudication resources, with no benefit flowing to the Veteran, and is unnecessary. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991). The Veteran is also in receipt of Social Security benefits. However, during the January 2010 hearing, he indicated that these benefits were based on his age as opposed to disability. Accordingly, any Social Security Administration (SSA) records are not relevant to the claim decided here and remand to obtain such records is unnecessary. See Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2010). The AMC has addressed the claim for service connection for gout on both direct and secondary bases. Under 38 C.F.R. § 19.29, a statement of the case (SOC) must contain, among other things, a summary of the applicable laws and regulations, with appropriate citations, and a discussion of how such laws and regulations affect the agency of original jurisdiction's determination. Here, neither the May 2008 SOC nor the April 2012, September 2012, or May 2013 SSOCs included citation to 38 C.F.R. § 3.310, the pertinent regulation regarding secondary service connection. However, as stated above, in the May 2013 SSOC, the AMC did state that service connection may be granted for a disease or injury which resulted from a service-connected disability or was aggravated thereby. In the April 2012 SSOC, the RO discussed that service connection could be established in several different ways and stated that service connection may be established on a secondary basis for disabilities which are proximately due to or the result of a service-connected disease or injury, citing Roper v. Nicholson, 20 Vet. App. 173, 178 (2006). Notably, the Veteran has been represented by an accredited representative during his appeal and, during the January 2010 hearing, his representative argued that the claimed conditions were related to the Veteran's ischemic heart disease. 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 absence of citation to 38 C.F.R. § 3.310 in an SOC or SSOC, in this case, is harmless error. See Soyini, above (strict adherence to requirements in the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the claimant); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the claimant are to be avoided). In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires that the RO Decision Review Officer or Veterans Law Judge who chairs a hearing to fulfill two duties: (1) the duty to fully explain the issue(s) and (2) the duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010). During the Board hearing, the undersigned Veterans Law Judge did not specifically discuss the criteria necessary to establish service connection for gout/gouty arthritis, to include as secondary to service-connected ischemic heart disease. However, the undersigned Veterans Law Judge did identify the issue of entitlement to service connection for gout and the Veteran's representative asserted that the Veteran's claimed disabilities were related to his ischemic heart disease. The Veterans Law Judge did ask questions regarding the Veteran's current treatment, in order to identify any outstanding evidence that may have been overlooked. Neither the Veteran nor his representative has alleged that there were any deficiencies in the Board hearing under section 3.103(c)(2). See Bryant, 23 Vet. App. at 497-98. The Veteran is not shown to be prejudiced in regard to any deficiencies in the January 2010 hearing. Significantly, in Bryant, 23 Vet. App. at 498-99, the Court held that although the hearing officer did not explicitly explain the material issues of medical nexus and current disability, the purpose of 38 C.F.R. § 3.103(c)(2) had been fulfilled because the record reflected that these issues were developed by VA, and there was no indication that the Veteran had any additional information to submit. In this case, given the extensive development of the Veteran's claim discussed above, the Board finds no deficiency in the Board hearing or in development of the claim. See id. 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. The Merits of the Claim In June 2007, the Veteran filed a claim for service connection for gout. In his July 2008 VA Form 646, the Veteran's representative reported that the Veteran contended that his claimed disabilities occurred while on active duty and were chronic in nature and, so, should be service connected. During his January 2010 hearing, the Veteran, through his representative, asserted that his gout was a result of his ischemic heart condition and was a result of treatment he was receiving for that condition. See Hearing Transcript, pages 8-11. 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 (2013). 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. Service connection can also be granted for certain chronic diseases, including arthritis, if manifest to a degree of 10 percent or more within one year of separation from active service. Such diseases shall be presumed to have been incurred in service even though there is no evidence of disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. A compensable evaluation for arthritis requires X-ray evidence. 38 C.F.R. § 4.71a, Diagnostic Code 5003. A disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. See 38 C.F.R. § 3.310(a). The Court has held that when aggravation of a nonservice-connected condition is proximately due to or the result of a service-connected condition the veteran shall be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. See Allen v. Brown, 7 Vet. App. 439 (1995). Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. However, VA will not concede a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. See 38 C.F.R. § 3.310(b) (2013). 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). As an initial matter, while the record reflects that the Veteran served in Vietnam, he has not claimed that his current gout/gouty arthritis is due to exposure to Agent Orange or other herbicides during service, nor does the record suggest such. During treatment at the VA cardiology clinic in August 2010, the Veteran's physician noted that the Veteran had reported being exposed to Agent Orange on multiple occasions during service. The physician observed that multiple disorders had been linked to Agent Orange exposure, including diabetes mellitus. In light of the Veteran's service, his presumed Vietnam chemical exposure, and his recent diagnosis of type II diabetes mellitus, the physician recommended that he be re-evaluated for service connection for his disorders. Significantly, the physician noted in the treatment record that the problems addressed on that date were chronic atrial fibrillation, newly diagnosed type II diabetes mellitus, non-ischemic cardiomyopathy, and peripheral vascular disease. The physician was clearly not rendering any opinion regarding the etiology of the Veteran's gout/gouty arthritis, but, rather, was suggesting a relationship between the Veteran's conditions evaluated on that date (chronic atrial fibrillation, newly diagnosed type II diabetes mellitus, non-ischemic cardiomyopathy, and peripheral vascular disease) and in-service herbicide exposure. A September 2003 VA Agent Orange program note states that the Veteran's problems included arthritis involving his knees and other joints; however, there is no indication that arthritis was related to the Veteran's Agent Orange exposure. Rather, this note simply appears to include a list of all of the Veteran's medical problems, with 28 items listed. Consistent with the Veteran's assertions, and the RO's adjudication of the claim, the Board is considering entitlement to service connection for the Veteran's claimed gout/gouty arthritis on a direct basis and as secondary to service-connected disability. Considering the pertinent evidence of record in light of the law, the Board finds that service connection for gout/gouty arthritis is not warranted. Service treatment records are negative for complaints regarding or treatment for gout and/or arthritis. In his Report of Medical History at separation in July 1967, the Veteran denied ever having swollen or painful joints, arthritis or rheumatism, and a bone, joint, or other deformity. On examination, clinical evaluation of the upper extremities, feet, and lower extremities was normal. In March 2001, the Veteran presented to his private physician with complaints of pain in his feet and legs. Arthritis profiles were negative but creatine phosphokinase was elevated. The physician advised the Veteran that his leg discomfort might improve if he took his blood pressure medication. He further noted that the Veteran had moderate to severe pes planus and was advised to use arch supports. When the Veteran returned a week later, he reported that his feet were much more comfortable after wearing orthotics and new shoes. A November 2001 neurologic consultation for painful legs documents the Veteran's complaint of episodic pain in the feet and lower legs. He gave a history of having had some bone spurs excised by a podiatrist and having surgery for plantar fasciitis. The neurologist's impression was that the Veteran's painful legs remained cryptogenic and he had objectively minimal neuropathy on bedside examination. A December 2001 private treatment record notes that the Veteran had pain in his left foot which was sometimes associated with activity and sometimes not. Examination of the hands revealed osteoarthritis with marked Heberden's nodes. The physician commented that he thought the Veteran had some osteoarthritis as well as peripheral arterial insufficiency with claudication of his left leg. In April 2002, the Veteran received treatment at Tennessee Orthopaedic Alliance for chronic pain, numbness, and weakness in both legs. He described a complex history of chronic pain in his legs which extended from his ankle up to his knee and down to his foot. The physician commented that X-rays of the foot and ankle in the past had been normal. The impression was probable tarsal tunnel syndrome, right lower extremity. In October 2003, the Veteran described significant left foot pain to his private physician. There was mild swelling in the dorsum of the foot with associated tenderness. X-rays of the left foot were negative. The impression was flare-up of arthritis in the foot. A June 2005 treatment record from another private physician, Dr. S.J.B., notes that the Veteran's left ankle was acutely inflamed after a fall. Dr. S.J.B. commented that the Veteran also had severe osteoarthritis as well as a history of gout; however, the Veteran's big toe was not inflamed and the inflammation was centered around the ankle joint itself and not any tendons. The assessment was monoarticular arthritis, left ankle, associated with osteoarthritis. In a September 2005 letter, Dr. S.J.B. stated that he had been the Veteran's primary care physician for 18 years. This physician wrote that, as a result of chronic administration of Amiodarone for his cardiac rhythm disturbances, the Veteran had developed hypothyroidism for which he took thyroid replacement. Dr. S.J.B. added that the Veteran had gradual renal insufficiency in association with chronic use of non-steroidal anti-inflammatory drugs and such had affected the use of a variety of medications, including further non-steroidal anti-inflammatory drugs which, while helping his joint discomfort and musculoskeletal complaints, further compromised his renal function. He added that the Veteran had acquired gout. In August 2006 the Veteran presented to the VA Medical Center (VAMC) with complaints of his big toe hurting. The assessment was gout and Colchicine was restarted. In October 2006, he presented with complaints of pain from his knuckle to his hand and wrist. His right hand was swollen and warm to the touch with mild erythema primarily over the second and third metacarpophalangeal joints. Swelling extended to the wrist. The assessment was right hand pain, probable gout. The physician noted that uric acid level was within normal limits, but, clinically, the Veteran's presentation looked like gout, so, it would be treated as such. X-ray study of the right hand revealed degenerative narrowing and spurring to a mild degree at the distal interphalangeal joints with arthritic change at the second metacarpophalangeal joint. The Veteran returned in November 2006 with complaints of right wrist pain, swelling, and erythema for two weeks, which he attributed to a gouty flare; however, he reported that he also may have injured himself. The assessment included right hand pain and gout. The Veteran was instructed to continue Allopurinol and not take Colchicine. During treatment a week later, he described continued right hand swelling and pain and reported that he had fallen twice since his October 2006 X-ray. The Veteran stated that he had been taking Colchicine because he thought his pain was gout; however, he was directed to stop taking this because there was no gout and he was experiencing diarrhea. X-ray study of the right hand revealed a degenerative arthritic change involving the distal interphalangeal joint of the second through fifth fingers and second metacarpophalangeal joint, unchanged from the October 2006 X-ray study. In an August 2007 letter the Veteran's private physician, Dr. S.J.B., stated, "It is uncertain to me if/whether gout arthropathy and gastroesophageal reflux can be easily assumed to be stress and or medication related consequences of his other conditions but since several of his metabolic disorders (thyroid, etc.) can be attributed to medication given for possible/probably service-related impairments/conditions, it can be argued that many issues, conditions and multiple co-morbidities that [the Veteran] has experienced, accumulated and has received treatment for privately by myself and other specialists separate from the VA system are indeed truly service related. Accordingly these issues and conditions ought to be seriously reconsidered in fairness to his original injuries, wounds, physical, emotional and auditory traumas, possible vitamin deprivation while in the infantry and battlefields in the line of military duty culminating in the multiple later years' disabling and impairing conditions that he's experienced." A November 2007 VA X-ray study of the left foot revealed no acute fracture or dislocation. The joint spaces were normal. A small artery calcification was present. X-ray study of the right foot revealed no soft tissue swelling, acute fracture, or dislocation. There was a moderate plantar calcaneal spur and a small artery calcification was present. The impression was moderate plantar calcaneal spur in the right foot and small artery calcification in both feet consistent with diabetes mellitus or chronic renal failure. The Veteran was seen in the VA podiatry clinic in January 2008 for numbness to the plantar aspect of the feet and pain to the bilateral arch area. The podiatrist noted that the Veteran had rheumatoid arthritis with ulnar deviation of the hands. He also noted that the Veteran reported that he was exposed to Agent Orange and had PTSD for which he took medication. The diagnosis was "Neuropathy (apparently secondary to Agent Orange) neuritis, fasciitis difficulty walking." He was prescribed Lac Hydrin lotion and night splints, and the podiatrist discussed the use of heat and ice stretching and no barefooted walking. He was given injections of Marcaine and Dexamethasone to the right foot. When the Veteran returned for follow-up a week later he reported that he had good pain relief from the previous treatment. The assessment was the same as a week earlier. He was given injections to the left foot and was casted for orthotics. A February 2008 VA physical therapy consultation report reflects that the Veteran's pain in his feet had largely diminished since he started using the orthotics, and his only current pain was below the left lateral ankle. The Veteran returned to the podiatry clinic in March 2008 with complaints of arch pain when using his orthotics. The assessment was the same as in January 2008 ("Neuropathy (apparently secondary to Agent Orange) neuritis, fasciitis difficulty walking"). The orthotics were adjusted. The Veteran reported to the podiatrist in April 2008 that the adjusted orthotics fit and felt good. He had no further complaints of foot pain. A July 2008 VA treatment record notes that the Veteran had gout and was on Allopurinol. Uric acid level was within goal at 5.4. The physician noted that the Veteran had flares of gout in the left wrist, with current possible flares in the right wrist; although the pain was described in a more linear fashion down the forearm and the wrist joint was not swollen, erythematous, or warm. The physician opined that this might be osteoarthritis. In a June 2011 letter, the Veteran's VA physician wrote a letter documenting several of the medical issues for which he had been following the Veteran, including chronic arthritis pain. The Veteran underwent a VA heart examination in March 2012. The examiner noted that the Veteran had been diagnosed with congestive heart failure and had chronic atrial fibrillation, both of which qualified within the generally accepted medical definition of ischemic heart disease. The examiner indicated that the Veteran did not have any other pertinent physical findings, complications, conditions, signs and/or symptoms related to his diagnosed heart disorders. The Veteran was afforded a VA examination to evaluate his claimed gout in August 2012. The examiner indicated that the Veteran had been diagnosed with gout in 2000 and his condition required continuous medication, specifically, Allopurinol. He indicated that this condition prevented exercise and sports, and had a moderate impact on chores, shopping, recreation, traveling, feeding, bathing, dressing, toileting, grooming, and driving. The examiner included X- ray studies of the bilateral feet, which revealed mild osteoarthritis of the tibiotalar joint of the right foot and mild osteoarthritis of the tibiotalar joint of the left foot and first metatarsophalangeal joint. The radiologist's impression was no obvious evidence of gout. X-ray studies of the bilateral hands revealed degenerative changes in the radiocarpal joint and intercarpal joints. The radiologist's impression was inflammatory-type arthritis with likely superimposed osteoarthritis. The VA examiner responded to the questions posed by the Board in its July 2012 remand. In response to the question, "Upon clinical examination, does the Veteran have current gout?" the examiner stated, "No." Confusingly, despite opining that the Veteran did not have current gout, he went on to respond to the other questions posed by the Board. In response to the question, "If current gout is diagnosed, is gout related to the Veteran's military service?" the examiner stated, "No." He again responded simply, "No." to the following questions: "If current gout is diagnosed, is gout proximately due to or the result of the Veteran's ischemic heart disease?" and "If current gout is diagnosed, is gout chronically aggravated or worsened by the Veteran's ischemic heart disease, regardless of the date of onset of either disorder?" The examiner noted, as was pointed out by the Board in July 2012, that service treatment records are negative for any complaint, treatment, or diagnosis of gout; post-service VA treatment records dated from 2006 to 2012 document current gout; a July 2008 VA treatment record notes gout in the wrists; the Veteran takes the prescription Colchicine to treat his recurrent gout; in September 2005 and August 2007, Dr. S.J.B., MD., the Veteran's primary care physician, vaguely opined it is "uncertain" whether gout is related to stress or medication from the Veteran's ischemic heart disease or other disorders; and the Veteran contended that his current gout is related to his service-connected ischemic heart disease. The examiner noted that his opinion was given after careful examination of the provided records and the Veteran, with relation to considered condition(s) and similar cases remarked in Cecil's and Harrison's Textbooks of Medicine and other medical literature. A September 2012 VA wheelchair clinic consultation report reflects that the Veteran had coronary artery disease and osteoarthritis which limited his walking. His chronic conditions, as reported by himself and documented in the Computerized Patient Record System (CPRS) included osteoarthritis of the hands. Diagnoses at that time included osteoarthritis and gout. Because of the confusing opinion provided by the August 2012 VA examiner, a supplemental medical opinion was obtained in March 2013. The physician was asked to provide an opinion as to whether the Veteran has had gout, arthritis in the hands and/or feet, and/or gouty arthritis at any time since June 2007 (when he filed his claim for service connection). The physician who provided the March 2013 opinion stated that the Veteran was diagnosed with gout in 2000, and so he had gouty arthritis since June 2007. In response to the request for an opinion as to whether any arthritis in the hands and/or feet, to include gouty arthritis, began within one year of discharge from active service, the physician stated that the Veteran was diagnosed with gout in 2000 and was separated from service in the 1960s. Therefore, he opined that his gout less likely than not began within one year of discharge from active service. The March 2013 VA report includes a restatement of the requested opinion. Specifically, the physician was to provide an opinion as to whether any gout, arthritis in the hands and/or feet, and/or gouty arthritis which had been present at any time since June 2007 began during active service or was related to any incident of service; was to provide an opinion as to whether any gout, arthritis in the hands and/or feet, and/or gouty arthritis which had been present at any time since June 2007 was proximately due to or the result of the Veteran's ischemic heart disease; and was to provide an opinion as to whether any gout, arthritis in the hands and/or feet, and/or gouty arthritis which had been present at any time since June 2007 was chronically aggravated or worsened by the Veteran's ischemic heart disease, regardless of the date of onset of either disorder. In response, the physician opined that it was less likely than not (less than 50 percent probability) that the claimed condition was incurred in or caused by the claimed in- service injury, event, or illness. In providing a rationale for this opinion, he stated that the Veteran's gout developed long after his time in service and gout is due to the abnormal metabolism of nucleic acids which leads to build up of uric acid crystals which leads to gout. He stated that gout was not caused by any of the Veteran's time in service. The physician also opined that the claimed condition was less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran's service- connected condition. In providing a rationale for this opinion, he stated that gout has no relation to ischemic heart disease. He noted that ischemic heart disease is due to decreased oxygen and blood flow to the heart and gout is caused by abnormal metabolism of nucleic acids which leads to build up of uric acid crystals which leads to gout. He reiterated that the two conditions have no relation to each other. The physician who provided the March 2013 opinion indicated by checked box that the claimed condition, which clearly and unmistakably existed prior to service, was clearly and unmistakably not aggravated beyond its natural progression by an in-service injury, event, or illness. While the physician marked the box for this opinion under the category of "Medical opinion for aggravation of a condition that existed prior to service" in the examination worksheet, it is clear from a reading of the examination report in its entirety (including the restatement of the requested opinion and the rationale provided) that the physician was simply attempting to respond to the request for an opinion as to whether the Veteran's gout/gouty arthritis was chronically aggravated or worsened by his ischemic heart disease. This conclusion is supported by the fact that, in providing a rationale for his opinion, the physician explained that gout has no relation to ischemic heart disease. He reiterated that ischemic heart disease is due to decreased oxygen and blood flow to the heart and gout is caused by abnormal metabolism of nucleic acids which leads to build up of uric acid crystals which leads to gout. He again stated that the two conditions have no relation to each other and, since there was no relation, gout would not be aggravated beyond its natural progression. The March 2013 opinion clarified that the Veteran had had gout/gouty arthritis since June 2007. This is corroborated by the numerous diagnoses of gout of record (as outlined above). Thus, the first element of the service connection claim is satisfied. Service treatment records are negative for complaints regarding or treatment for gout/gouty arthritis. While, in July 2008, the Veteran asserted that each of his claimed conditions occurred during his time on active duty, such assertion is outweighed by the Veteran's July 1967 Report of Medical History at separation, in which he denied ever having swollen or painful joints, arthritis or rheumatism, and a bone, joint, or other deformity. On examination, clinical evaluation of the upper extremities, feet, and lower extremities was normal. These medical records are highly probative both as to the Veteran's subjective reports and their resulting objective findings. They were generated with a view towards ascertaining the Veteran's then-state of physical fitness and are 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). Accordingly, the assertion that the Veteran experienced gout during service is not credible. Although the Veteran served in combat, he does not contend, nor does the evidence indicate, that gout/gouty arthritis was incurred in combat with the enemy. Therefore, 38 U.S.C.A. § 1154(b), pertaining to proof of service incurrence or aggravation of a disease or injury in the case of a veteran who engaged in combat with the enemy is not for application. Service connection for gouty arthritis based on chronicity or continuity of symptomatology is for consideration, as arthritis is a chronic disease listed in 38 C.F.R. § 3.309(a). While the Veteran has not specifically asserted a continuity of symptomatology of gout/gouty arthritis since service, he alleged (via his representative in July 2008) that his disorder was caused while in service and was chronic in nature. Nevertheless, the Board finds such assertions to be outweighed by the evidence of record, including the Veteran's own denial of swollen or painful joints, arthritis or rheumatism, and a bone, joint, or other deformity in July 1967 and the normal clinical evaluation of the upper extremities, feet, and lower extremities at that time. These records are more probative than the July 2008 assertion, and weigh against a finding of chronicity or continuity of symptomatology of gouty arthritis since service. Thus, service connection based on chronicity or continuity of symptomatology pursuant to 38 C.F.R. § 3.303(b) is not warranted. 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 current gout/gouty arthritis and service, however, must be established by evidence of a nexus. See Walker, 708 F.3d at 1338-39. In his August 2007 letter, which discussed the Veteran's gout arthropathy, Dr. S.J.B. did state that it could "be argued that many issues, conditions and multiple co- morbidities that [the Veteran] has experienced, accumulated and has received treatment for privately by myself and other specialists separate from the VA system are indeed truly service related. Accordingly these issues and conditions ought to be seriously reconsidered in fairness to his original injuries, wounds, physical, emotional and auditory traumas, possible vitamin deprivation while in the infantry and battlefields in the line of military duty culminating in the multiple later years' disabling and impairing conditions that he's experienced." However, this physician's opinion, that it could "be argued" that many of the Veteran's conditions were service-related and his statement that a relationship to service "ought to be reconsidered" are simply too speculative to grant service connection. See Bostain v. West, 11 Vet. App. 124, 127-28 (1998), quoting Obert v. Brown, 5 Vet. App. 30, 33 (1993) (medical opinion expressed in terms of "may" also implies "may or may not" and is too speculative to establish a medical nexus). By contrast, the physician who provided the March 2013 opinion opined that it was less likely than not (less than 50 percent probability) that the claimed condition (gout/gouty arthritis) was incurred in or caused by the claimed in-service injury, event, or illness. This opinion was based on review of the claims file, which includes the August 2007 opinion from Dr. S.J.B. Significantly, the March 2013 VA examination request drew the physician's attention to several specific items of evidence, including Dr. S.J.B.'s September 2005 and August 2007 letters. The physician explained the basis for his opinion, specifically, the Veteran's gout developed long after his time in service and gout is due to the abnormal metabolism of nucleic acids which leads to build up of uric acid crystals which leads to gout. This March 2013 opinion is highly probative. 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 v. Brown, 4 Vet. App. 467, 470- 71 (1993) (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 March 2013 opinion was based, in part, on a finding that the Veteran's gout developed long after his time in service and the physician stated that the Veteran was diagnosed with gout in 2000. While the record presently before the Board does not document a diagnosis of gout in 2000, this finding appears to be based on the Veteran's history of his condition as reported to the August 2012 VA examiner. During the August 2012 VA examination, the Veteran reported to the examiner that he had been diagnosed with gout in 2000. The Veteran previously asserted, via his representative, in July 2008, that his gout occurred during his time on active duty. Where a Veteran has provided lay testimony of an in-service injury, unless the Board finds that the testimony is not credible, an examiner may not ignore that lay evidence and base his or her opinion that there is no relationship to service on the absence of in- service corroborating medical records. Dalton v. Nicholson, 21 Vet. App. 23, 39-40 (2007). However, as discussed above, such assertion of gout during service has been determined to be not credible. Therefore, to the extent that the March 2013 opinion is based on the absence of gout during and for a long time after service, it is adequate. The March 2013 opinion is the most persuasive medical opinion that addresses the question of a nexus between current gout/gouty arthritis and service. Thus, the competent, probative (persuasive) evidence on the question of whether gout/gouty arthritis was incurred in or aggravated by service weighs against the claim for service connection. While, in March 2013, the Board found the August 2012 VA examiner's opinion to be inadequate (in that it was confusing because the examiner stated that the Veteran did not have current gout, but then went on to provide etiological opinions regarding the Veteran's gout), this August 2012 opinion further supports the March 2013 opinion as the August 2012 VA examiner opined that the Veteran's gout was not related to his military service. The August 2012 opinion was based on review of the claims file, examination of the Veteran, and consideration of pertinent medical literature. The August 2012 VA examiner explained the basis for his opinion, including consideration of similar cases in medical texts, and noted the fact that that service treatment records were negative for any complaint, treatment, or diagnosis of gout. Accordingly, service connection on a direct basis is not warranted. Additionally, there is no evidence that gouty arthritis manifested itself to a compensable degree within one year of the Veteran's separation from military service. Rather, arthritis profiles were negative in March 2001. The first mention of arthritis is the December 2001 private treatment record noting osteoarthritis in the hands and left leg. Although the Veteran's physician commented in April 2002 that X-rays of the foot and ankle in the past had been normal, and another physician who saw the Veteran for significant left foot pain in October 2003 noted that X-rays of the left foot were normal, the October 2003 physician gave an impression f flare-up of arthritis in the foot. During treatment in June 2005, Dr. S.J.B. commented that the Veteran had severe osteoarthritis as well as a history of gout; however, it was not until October 2006 that X-rays documented degenerative narrowing and spurring with arthritic change in the right hand. Significantly, November 2007 VA X-ray studies of the feet do not mention arthritis. Osteoarthritis in the feet was later documented in the X-ray studies obtained in conjunction with the August 2012 VA examination. Inflammatory-type arthritis with likely superimposed osteoarthritis in both hands was also revealed in the August 2012 X-ray studies. There is simply no X-ray evidence of arthritis (to include gouty arthritis) in the hands and/or feet within one year of separation from service. Thus, service connection is not warranted for hypertension on a presumptive basis. See 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Regarding the assertion that the Veteran's gout/gouty arthritis is caused or aggravated by his service-connected ischemic heart disease (to include medication used to treat that service-connected disability), Dr. S.J.B.'s August 2007 opinion that it was "uncertain" whether gout arthropathy was related to stress or medication is speculative. See Bostain, supra. By contrast, the physician who provided the March 2013 opinion opined that the Veteran's gout/gouty arthritis was less likely than not proximately due to or the result of the Veteran's service-connected condition. This opinion was based on review of the claims file (including the August 2007 letter from Dr. S.J.B.) and the opinion was supported by a clearly-stated rationale. Specifically, ischemic heart disease is due to decreased oxygen and blood flow to the heart and gout is caused by abnormal metabolism of nucleic acids which leads to build up of uric acid crystals which leads to gout and the two conditions have no relation to each other. The physician also opined that the Veteran's gout was not aggravated by his service-connected ischemic heart disease, as he explained that since there was no relation between gout and ischemic heart disease, gout would not be aggravated beyond its natural progression. While the March 2013 VA opinion did not specifically address the question of whether the Veteran's gout/gouty arthritis was proximately due to, the result of, or chronically aggravated or worsened by medication used to treat the Veteran's service-connected ischemic heart disease, the physician nevertheless acknowledged review of the claims file and the March 2013 VA examination request specifically highlighted the fact that Dr. S.J.B. had opined that it was "uncertain" whether gout is related to stress or medication from the Veteran's ischemic heart disease or other disorders. Thus, the March 2013 opinion that there is no relation between the Veteran's gout and ischemic heart disease would have included consideration of medication used to treat service-connected ischemic heart disease. The March 2013 opinion is the most persuasive medical opinion that addresses the question of a relationship between current gout/gouty arthritis and service-connected ischemic heart disease. Thus, the competent, probative (persuasive) evidence on the question of whether gout/gouty arthritis was caused or aggravated by either of this service-connected disability weighs against the claim for service connection. The Board previously found the August 2012 VA examiner's opinion to be inadequate because it was confusing since the examiner stated that the Veteran did not have current gout, but then went on to provide etiological opinions regarding the Veteran's gout. However, this August 2012 opinion does support the March 2013 opinion as the August 2012 VA examiner opined that the Veteran's gout was not proximately due to or the result of the Veteran's ischemic heart disease and was not chronically aggravated or worsened by the Veteran's ischemic heart disease. The August 2012 opinion was based on review of the claims file, examination of the Veteran, and consideration of pertinent medical literature. The August 2012 VA examiner explained the basis for his opinion, including consideration of similar cases in medical texts, and noted the fact that that service treatment records were negative for any complaint, treatment, or diagnosis of gout. Accordingly, service connection on a secondary basis is also not warranted. In addition to the medical evidence, the Board has considered the Veteran's contention that he has gout/gouty arthritis related to service and/or service-connected ischemic heart disease. 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 Board therefore finds that the etiology of his gout/gouty arthritis is beyond his competence. Moreover, the question of etiology of this condition is complex in nature. Therefore, to the extent he has asserted that he has gout/gouty arthritis related to service and/or service- connected ischemic heart disease, the Board finds such assertions to be of little probative value, especially in relation to the March 2013 and August 2012 VA examiner's opinions, as the Veteran is not competent to opine on these complex medical questions. His contentions regarding etiology of his current gout/gouty arthritis are outweighed by the medical evidence of record, specifically the opinions of the March 2013 and August 2012 VA examiners. The preponderance of the evidence is against the claim and the appeal will be denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. ORDER Service connection for gout/gouty arthritis, to include as secondary to service-connected ischemic heart disease, is denied. ____________________________________________ Vito A. Clementi Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs