Citation Nr: 1334710 Decision Date: 10/30/13 Archive Date: 11/06/13 DOCKET NO. 04-03 935 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUES 1. Entitlement to service connection for hypertension, including due to service-connected disabilities. 2. Entitlement to an increased rating for Reiter's syndrome in excess of 40 percent prior to June 11, 2013, and in excess of 60 percent thereafter. REPRESENTATION Appellant represented by: Mississippi Veterans Affairs Commission WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD T. M. Gillett, Counsel INTRODUCTION The Veteran served on active duty from January 1975 to May 1983. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2003 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Jackson, Mississippi, which continued an assigned 40 percent evaluation for Reiter's syndrome; and denied service connection for hypertension, indigestion, gastroesophageal reflux disorder (GERD), stomach problems, and irritable bowel syndrome (IBS). The Veteran testified at a videoconference hearing in August 2006 before the undersigned Veterans Law Judge (VLJ). In April 2008, the Veteran also testified before a Decision Review Officer (DRO). In a March 2007 Decision, the Board denied service connection for irritable bowel syndrome (IBS). Therefore, that issue is no longer in appellate status and is not before the Board. In the same document, the Board remanded the Veteran's claims for an increased rating for Reiter's syndrome, and service connection for hypertension, indigestion, GERD, and stomach problems to the Appeals Management Center (AMC) for development. The AMC subsequently recertified the claim to the Board. In June 2012, at the Board's request, a VA clinician from the Veterans Health Administration (VHA) provided a medical opinion regarding the etiology of the Veteran's claimed hypertension disorder. In August 2012, the same examiner provided an additional opinion. Copies of both opinions were provided to the Veteran and associated with the claims file. In a May 2013 Decision, the Board granted the Veteran's claims for service connection for indigestion, GERD, and a stomach disorder, specifically gastritis. As the May 2013 Decision fully granted these claims, they are no longer in appellate status and are not before the Board. In the same document, the Board remanded the claims for an increased rating for Reiter's syndrome and service connection for hypertension to the AMC for further development. In a subsequent July 2013 rating decision, the AMC partially granted the Veteran's claim for an increased rating for Reiter's syndrome, evaluating the disability as being 60 percent disabling, effective June 11, 2013. The AMC then recertified the issues to the Board. A review of the Virtual VA paperless claims processing system reveals no additional documents pertinent to this appeal. The issue of an increased rating for Reiter's syndrome is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC) in Washington, DC. FINDINGS OF FACT 1. The Veteran's hypertension did not have its onset in active duty service and is not otherwise related to active duty service, to include on a presumptive basis. 2. The Veteran's hypertension was not caused or permanently aggravated by the Veteran's service-connected disabilities. CONCLUSION OF LAW The criteria for entitlement to service connection for hypertension have not been met. 38 U.S.C.A. §§ 1110, 1112, 1113, 1131, 1137, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Introductory Matters 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 United States Court of Appeals for the Federal Circuit (Federal Circuit) (as noted by citations to "Fed. Cir.") and the United States Court of Appeals for Veterans Claims (Court) (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. 38 U.S.C.A. § 7104(d) (West 2002 & Supp. 2012); see also 38 C.F.R. § 19.7 (2012) (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). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify a veteran and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim, and to indicate which information and evidence VA will obtain and which information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). The notice must be provided to the veteran prior to the initial adjudication of his or her claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). VCAA notice requirements apply to all five elements of a service connection claim: (1) veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 486 (2006). VA satisfied its duty to notify the Veteran by issuing notice letters in February 2005 and April 2007. In the February 2005 letter, VA informed the Veteran about the information and evidence not of record that was necessary to substantiate the claims; the information and evidence that VA would seek to provide; the information and evidence the Veteran was expected to provide; and specific information regarding the substantiation of a claim for service connection for a disorder secondary to an already service-connected disability. In an April 2007 letter, VA informed the Veteran about the information regarding disability ratings and effective dates required by Dingess. VA sent these required VCAA notice letter after initially deciding the Veteran's claim; the February 2005 and April 2007 letters were thus untimely. VA cured these timing defects later, however, by readjudicating the Veteran's claims in a Supplemental Statement of the Case issued in May 2011. Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007). The duty to assist provisions of the VCAA have been met. The claims file contains service treatment records, reports of post-service medical treatment, and reports of a VA medical examination provided in June 2013. In the June 2013 VA medical examination report, a VA examiner, after a review of all evidence, lay and medical, provided an opinion regarding the etiology of the claimed hypertension disorder. Therefore, the Board finds that the VA medical examination report has probative value in this matter. See Prejean v. West, 13 Vet. App. 444, 448 (2000) (indicating that the Board may determine the probative value of medical opinions based on their detail, the persuasiveness of their opinions, and the physicians' access to a veteran's medical records). The record indicates that the AMC complied with the March 2007 Remand requests, by issuing the April 2007 VCAA notice letter and obtaining the required records. In May 2013, the Board remanded the issue before it to the AMC for the provision of a VA medical examination to determine the nature and etiology of the Veteran's claimed hypertension disorder. After obtaining the June 2013 VA medical examination report, the AMC recertified the Veteran's claim to the Board. VA has fulfilled its duty to assist the Veteran by providing the Veteran with proper notice, procuring the required medical records, and providing the Veteran with a proper VA medical examination. Therefore, the Board finds that the AMC complied with the Board's Remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). Regarding the August 2006 videoconference hearing, in Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) (2012) requires that the VLJ who conducts a hearing fulfill two duties to comply with the above regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. During the August 2006 videoconference hearing, the VLJ specifically noted the issues on appeal. The VLJ sought to identify any pertinent evidence not currently associated with the claims folder that might have been overlooked or was outstanding that might substantiate the claim. Both the VLJ and the Veteran's representative specifically queried the Veteran regarding any evidence the Veteran might have regarding the nature and etiology of his claimed hypertension disorder. Partially as a result of these inquiries, the VLJ determined that a VA medical examination was necessary to assist in determining the nature and etiology of the claimed hypertension disorder. The Board subsequently remanded the claim. In this case, the VLJ substantially complied with the requirements of Bryant. The Veteran has not made VA aware of any additional evidence that must be obtained in order to fairly decide the appeal. He has been given ample opportunity to present evidence and argument in support of his claim. Pursuant to 38 C.F.R. § 3.655 (2012), all relevant evidence necessary for an equitable disposition of the Veteran's appeal of this issue has been obtained and the case is ready for appellate review. General due process considerations have been complied with by VA. See 38 C.F.R. § 3.103 (2012). Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110, 1131; 38 C.F.R. § 3.303. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Service connection may also be granted for any disease diagnosed after discharge, 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 order to establish service connection for the claimed disorder, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical, or in certain circumstances, lay evidence of a nexus between the claimed in-service disease or injury and the current disability. See 38 C.F.R. § 3.303; see also Hickson v. West, 12 Vet. App. 247, 253 (1999); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). 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 v. Shinseki, 708 F.3d 1331, 1339 (Fed. Cir. 2013) (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 causes unrelated to service ("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. The Federal Circuit noted that the requirement of showing a continuity of symptomatology after service is a "second route by which a veteran can establish service connection for a chronic disease" under subsection 3.303(b). Walker, 708 F.3d at 1336. Showing a continuity of symptoms after service itself "establishes the link, or nexus" to service and also "confirm[s] the existence of the chronic disease while in service or [during the] presumptive period." Id. (holding that section 3.303(b) provides an "alternative path to satisfaction of the standard three-element test for entitlement to disability compensation"). Significantly, the Federal Circuit indicated that showing a continuity of symptomatology after service is a lesser evidentiary burden than the nexus requirement of the three-part test discussed above: "The primary difference between a chronic disease that qualifies for § 3.303(b) analysis, and one that must be tested under § 3.303(a), is that the latter must satisfy the 'nexus' requirement of the three-element test, whereas the former benefits from presumptive service connection . . . or service connection via continuity of symptomatology" (emphasis added). Id. at 1339. 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). Id. at 1338-40. 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 "medical nexus of a relationship [sic] between the condition in service and the present condition is required." Id. at 1338; see also id. at 1336, 1340 (holding that the claimant's allegation of a continuity of hearing loss ever since active service was not sufficient to support the claim under subsection 3.303(b), as hearing loss was not among the chronic diseases listed in section 3.309(a)). Because the Veteran has been diagnosed with hypertension, a form of cardiovascular-renal disease, the provisions of subsection 3.303(b) for chronic disabilities apply, and the Veteran's claim for service connection for hypertension may be supported by evidence of a continuity of symptomatology after service. Service connection also may be granted for the listed chronic diseases, to include hypertension, when they are manifested to a compensable degree within one year of separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. A disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310(a). Secondary service connection may also be established for a nonservice-connected disability which is aggravated by a service connected disability. Aggravation is defined for legal purposes as a permanent worsening of the underlying condition beyond its natural progression, versus a temporary flare-up of symptoms. In such an instance, the veteran may be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.310(b); see Allen v. Brown, 7 Vet. App. 439, 448 (1995). A claim for secondary service connection requires medical evidence that connects the asserted secondary disorder to the service-connected disability. Velez v. West, 11 Vet. App. 148, 158 (1998). In order to establish entitlement to service connection on this secondary basis, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a nexus (i.e., link) between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). For VA rating purposes, hypertension means that the diastolic blood pressure is predominantly 90 mm Hg or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160 mm Hg or greater with a diastolic blood pressure of less than 90 mm Hg. Hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days. 38 C.F.R. § 4.104, Diagnostic Code 7101, Note (1) (2012). In all cases, 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 three-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 this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. 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, 511-12 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table); see Madden v. Gober, 125 F.3d 1477, 1481 (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, 1 Vet. App. at 49. The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). The Board has considered all evidence of record as it bears on the question of service connection. See 38 U.S.C.A. § 7104(a) (West 2002 & Supp. 2012) ("Decisions of the Board shall be based on the entire record in the proceeding and upon consideration of all evidence and material of record"); 38 U.S.C.A. § 5107(b) ("Secretary shall consider all information and lay and medical evidence of record in a case"). Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. The Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the Veteran's appeal. Service Connection for Hypertension Having reviewed the evidence of record, the Board finds that the Veteran's claimed hypertension disorder did not have its onset in active duty service, and is not otherwise related to active duty service, to include on a presumptive basis. The Board also finds that the Veteran's hypertension disorder was neither caused nor permanently aggravated by his service-connected Reiter's syndrome and/or mood disorder. The Board notes that the Veteran has not contended that his diagnosed hypertension disorder is related to service or any incident of service. At the August 2006 videoconference hearing, the Veteran stated that he was diagnosed with hypertension in 2003, approximately two decades after his May 1983 discharge from service. When asked what he believed caused the onset of hypertension in 2003, the Veteran reported, in part, that the stress related to losing his job and being unable to work at that time probably contributed to an increase in blood pressure. The Veteran did not experience chronic hypertension disorder symptomatology during service. For VA purposes, the minimum criteria for a hypertension diagnosis is met when the diastolic blood pressure is predominantly 90 mm Hg or greater. The minimum criteria for isolated systolic hypertension are met when the systolic blood pressure is predominantly 160mm Hg or greater with a diastolic blood pressure of less than 90 mm Hg. Hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days. 38 C.F.R. § 4.104, Diagnostic Code 7101, Note (1) In an October 1974 service entrance examination report, a VA service examiner noted that the Veteran's blood pressure was 130 mm Hg (systolic blood pressure) over 86 mm Hg (diastolic blood pressure). The service treatment records do not contain any blood pressure readings of systolic blood pressure of 160 mm Hg or greater. Therefore, the record does not contain any indications of in-service blood pressure readings meeting the VA regulatory criteria for a diagnosis of isolated systolic hypertension. In a November 1976 service treatment record, a service examiner noted a blood pressure reading of 140 mm Hg over 100 mm Hg. Subsequently, in a December 1982 service treatment record, a service examiner noted a blood pressure reading of 140 mm Hg over 90 mm Hg. Therefore, the service treatment records contain two records indicating diagnosed diastolic blood pressure of 90 mm Hg or greater. Yet, the diagnostic criteria for hypertension for VA ratings purposes is met when diastolic blood pressure is predominantly 90mm Hg or greater over multiple readings. The Veteran's service treatment records contain only seven blood pressure readings with only two reports of diastolic pressure of 90 mm Hg or greater out of a possible seven, the record indicates that the Veteran did not experience diastolic blood pressure that was predominantly 90 mm Hg or greater during service. Therefore, the Veteran did not experience in-service diastolic pressure readings meeting the VA regulatory criteria for a diagnosis of hypertension. In a February 1983 service discharge medical examination report, a service examiner noted a blood pressure reading of 112 over 88. Therefore, the Veteran's blood pressure did not meet the VA regulatory criteria for a diagnosis of hypertension or isolated systolic hypertension at discharge. Therefore, the Board finds that the Veteran did not experience chronic hypertension disorder symptomatology during service. The Veteran did not experience hypertension disorder symptomatology manifested to a compensable degree within one year of separation from service. In order to qualify for a compensable (10 percent) rating under VA regulations, a Veteran's hypertension disorder must be manifested by hypertensive vascular disease with diastolic pressure predominantly 100 mm Hg or more, systolic pressure predominantly 160 mm Hg or more, or a history of diastolic pressure predominantly 100 mm Hg or more requiring continuous medication for control. 38 C.F.R. § 4.104, Diagnostic Code 7101. VA treatment records dated within one year of the Veteran's May 1983 date of discharge do not contain findings more nearly approximating that required for a compensable rating. In an April 1984 VA medical examination report, a VA examiner recorded blood pressure readings of 130 mm Hg over 70 mm Hg (sitting), 126 mm Hg over 70 mm Hg (recumbent), 138 mm Hg over 72 mm Hg (standing), 142 mm Hg over 74 mm Hg (sitting after exercise), and 140 mm Hg over 76 mm Hg (two minutes after exercise). Subsequently, In a May 1984 VA treatment record, a VA examiner recorded a blood pressure reading of 124 mm Hg over 86 mm Hg. These readings do not meet the criteria for either a compensable rating for hypertension or a diagnosis of hypertension under the applicable VA regulations. See id. Therefore, the Board cannot grant service connection for hypertension under a presumptive basis. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. In addition, the Veteran did not experience continuous hypertension disorder symptomatology since his May 1983 service discharge. As noted above, the Veteran did not experience hypertension disorder symptomatology meeting the criteria for a diagnosis of hypertension under VA regulations within one year of his discharge from service. Since his May 1983 discharge, the record does not contain any blood pressure readings suggestive of hypertension, specifically a finding of diastolic pressure of 90 mm Hg or greater, until February 1989. In the February 1989 VA treatment record, a VA examiner noted that the Veteran's blood pressure was 126 mm Hg over 92 mm Hg. Although a VA examiner recorded another blood pressure reading of 126 mm Hg over 92 mm Hg in a December 1989 VA treatment record, the record indicates that the Veteran subsequently did not experience diastolic blood pressure readings predominantly measuring 90 mm Hg or greater required to meet the regulatory definition for hypertension around that time as other blood pressure readings were essentially normal. For example, in a November 1990 VA treatment record, containing a five-reading blood pressure check, a VA examiner noted that the Veteran's blood pressure readings fell below that required for a diagnosis of hypertension. The record does not contain a confirmed diagnosis of hypertension until July 2000, more than 17 years after the Veteran's discharge from service. Therefore, the record does not indicate that the Veteran experienced continuous hypertension disorder symptomatology since discharge from service. The record also does not indicate that the Veteran's blood pressure is related directly to service or any incident of service. The record does not contain any competent evidence from a medical professional suggesting any relationship between the Veteran's hypertension and service. Moreover, in his lay statements, the Veteran has stated that he developed hypertension years after his entry into service, as shown in the treatment evidence of record. The Veteran has not contended that his hypertension was caused directly by service or any incident in service. Instead, the Veteran has contended that his hypertension was caused or permanently aggravated by a service-connected disability. Therefore, the evidence indicates that the Veteran's hypertension is not related directly to his service or any incident of service. The Veteran essentially contends that his hypertension was caused or aggravated by his service-connected disabilities, specifically his Reiter's syndrome and his mood disorder. Having reviewed the evidence of record, the Board finds that the Veteran's currently diagnosed hypertension disorder was neither caused nor aggravated (permanently worsened) by his service-connected disabilities, to include his Reiter's syndrome and/or mood disorder. The record indicates that the Veteran experienced Reiter's syndrome symptomatology since his May 1983 service discharge and mood disorder symptomatology since 2004. In a September 2000 VA joints examination report, not otherwise relevant to this claim, the Veteran indicated that he recently had lost his job as a medical technician and had difficulty maintaining employment. In a November 2000 VA treatment record, a VA examiner noted that the Veteran had been diagnosed with hypertension in July 2000 and was on medication. Multiple treatment records included in the claims file indicate fluctuation of blood pressure readings since the Veteran's discharge. These treatment records, dated over the course of three decades, contain only seven reports of blood pressure suggestive of the criteria for a diagnosis of hypertension under VA regulations. See 38 C.F.R. § 4.104, Diagnostic Code 7101, Note (1). Specifically, in February 1989, December 1989, August 1990, May 1991, August 2002, November 2002, and August 2010, examiners noted diastolic pressure readings exceeding 90 mm Hg. In only one instance, specifically in August 2002, did an examiner note a reading of systolic pressure over 160 mm Hg. As the Veteran had his pressure checked very often, usually multiple times per year, the seven readings that suggest symptomatology meeting the minimum criteria for hypertension for VA purposes appear sparse in comparison. In a July 2003 VA medical opinion, a VA examiner reported reviewing the claims file and discussing the matter with a VA rheumatologist. Having done so, the VA examiner reported that the rheumatologist opined that there was no etiological link between the Veteran's hypertension and Reiter's syndrome. During the August 2006 videoconference hearing, the Veteran testified that he was initially diagnosed with hypertension in 2003. When asked what he believed caused his hypertension, the Veteran stated that he believed that the "stress of losing my job and not being able to work" caused the disorder. When asked by his representative to state why he believed that his hypertension should be service connected, the Veteran added that he believed that stress from financial difficulties related to an inability to work and marital difficulties contributed to his stress. When asked again why he believed that his hypertension should be service connected, the Veteran stated that he believed that it might have been caused by pain related to the medical conditions caused by his service-connected Reiter's syndrome. The Veteran specifically indicated that he did not have any opinions from medical professionals supporting his claim. In a January 2008 VA medical examination report, the Veteran reported experiencing hypertension symptomatology dating back to 1999. The Veteran stated that he took two medications for control of the disorder. The Veteran indicated that he was "asymptomatic concerning his hypertension." Upon examination, the Veteran's blood pressure was 130 mm Hg over 84 mm Hg (left arm sitting), 120 mm Hg over 80 mm Hg (supine) and 120 over 80 mm Hg (sitting). The VA examiner diagnosed essential hypertension. At an April 2008 DRO hearing, the Veteran testified that he developed hypertension in 1999, after onset of his Reiter's syndrome. When asked by his representative if a doctor or medical professional had to told him that his hypertension was due to his service-connected Reiter's syndrome, the Veteran stated that one had. When asked to clarify, the Veteran stated that "they told me that the stress of worrying and pain I have, from worrying with it makes my blood pressure, hypertension go up...." The Veteran stated that he was "in pain a lot which tends to make me, my hypertension go up a little bit. Over a period of time it would stay high from worrying about the problems I have." The Veteran indicated that as long as he took his hypertension medication and tried "to keep myself from worrying so much about the other problems I have," he could control his hypertension. The Veteran did not mention the name of the doctor or medical professional who reportedly indicated a link between his hypertension and his service-connected Reiter's syndrome. In a June 2012 VHA medical opinion, when asked if the Veteran's hypertension was caused or aggravated (chronically worsened) by the Veteran's service-connected Reiter's syndrome with chronic bilateral uveitis, a VA clinician wrote that, during review of the claims file, he "did not identify any indications of hypertension episodes related to arthritis." The VA clinician further stated that the current "medical literature in medical texts" did not "relate hypertension to Reiter's syndrome." The VA clinician concluded that the Veteran's "hypertension is more related to age and genetic predisposition." When asked to comment as to whether the Veteran's hypertension was caused or aggravated by the Veteran's other service-connected disabilities, to include a mood disorder, and left ankle and heel disabilities, the VA clinician wrote that the current medical literature did not support a connection between "depression and other medical diagnoses." The VA clinician also stated that the hypertension was not "related to left heel and ankle disabilities." In a subsequent December 2012 VHA medical opinion, the VA clinician wrote that the Veteran's left heel and ankle disabilities "did not aggravate, exacerbate, or cause hypertension." In a June 2013 VA medical examination report, a VA examiner noted reviewing the claims file prior to writing his report. During an interview, the Veteran stated that he had been diagnosed with essential hypertension in 1999 and had been on medication since that time. The Veteran indicated that his hypertension had been under relatively good control since that time. After an examination, to include blood pressure readings of 120 mm Hg over 80 mm Hg, 120 mm Hg over 70 mm Hg, and 120 mm Hg over 80 mm Hg, the VA examiner diagnosed essential hypertension. The VA examiner found that the Veteran's hypertension was not caused or permanently aggravated by the Veteran's service-connected Reiter's syndrome and/or mood disorder. In explaining this, the VA examiner stated that the "literature does not support a relationship between Reiter's syndrome and hypertension." The VA examiner noted that the Veteran was not taking medication for his Reiter's syndrome at that time and, therefore, there was no relationship between the Veteran's hypertension and medications taken for Reiter's syndrome. The VA examiner noted that the Veteran was taking medication, specifically bupropion, for his mood disorder. The examiner indicated that this medication could aggravate hypertension, but he found no evidence indicating that this had happened. The VA examiner noted that, in reviewing the Veteran's blood pressure readings from the previous two years, he found the readings to be basically normal or only slightly elevated at times. The examiner opined that it was less likely than not that the Veteran's hypertension was caused or aggravated by the Veteran's Reiter's syndrome or mood disorder. The preponderance of the evidence is against the claim. The Veteran was diagnosed with hypertension and given medication after onset of his Reiter's syndrome, but prior to the onset of his mood disorder symptomatology. During the previous three decades, the Veteran's hypertension was manifested by symptomatology even suggestive of that required for a hypertension diagnosis under VA regulations on only seven isolated occasions. The overwhelming majority of blood pressure readings include no reading suggestive of the symptomatology required for a hypertension diagnosis under VA regulations. The VA medical examination reports and VHA medical opinions of record contain opinions, indicating that the Veteran's hypertension was neither caused nor aggravated by any of the Veteran's multiple service-connected disabilities. As these examinations and opinions were based on the evidence, both lay and medical, in the claims file as of the date of their compositions, the Board finds that they have probative value in this matter. See Prejean, 13 Vet. App. at 448. In August 2006 the Veteran testified stated that he had not been told by any doctor or medical professional that his hypertension was either caused or aggravated by his service-connected disabilities. Subsequently, at the April 2008 DRO hearing, the Veteran stated that a doctor or medical profession had told him that his service-connected disabilities, to include Reiter's syndrome and a mood disorder, caused stress which made his blood pressure rise. The Veteran indicated that his blood pressure would go up a little bit and stay at a high level from worrying over his problems. The Veteran indicated that as long as he took his hypertension medication and tried "to keep myself from worrying so much about the other problems I have," he could control his hypertension. The Veteran did not identify the doctor who reportedly told him that there was a nexus between his hypertension and his service-connected disabilities. As the three decades of post-service treatment records on file contain no medical opinion indicating a positive relationship between the Veteran's hypertension and his service-connected disabilities, the Board finds that the Veteran's account is inconsistent with the medical evidence of record and, therefore, lacks credibility. See Caluza, 7 Vet. App. at 511-12. Moreover, the Veteran's account of the doctor's remarks would not establish a sufficient nexus between hypertension and a service-connected disability to allow for a grant of service connection. Under VA regulations, secondary service connection may be granted if a service-connected disability aggravates, or permanently worsens, a claimed disorder. In his testimony before the DRO, the Veteran indicated that a doctor told him that his blood pressure would temporarily rise during periods of stress and pain. Yet, the Veteran also indicated that he could control his hypertension by trying not to worry and taking his medication. The Veteran did not state that any medical professional told him that his service-connected disabilities had caused a permanent aggravation of his hypertension. Therefore, even when taken at face value, the Veteran's account of what the doctor told him is insufficient to allow for a grant of service connection for hypertension. For the above reasons, the Board finds that the preponderance of evidence weighs against the claim for service connection for hypertension and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. ORDER Service connection for hypertension is denied. REMAND In May 2013, the Board remanded the issue of an increased rating for Reiter's syndrome to the AMC for further development. The AMC did not fully comply with the Board's May 2013 Remand instructions dealing with the provision of a medical examination to determine the severity of the Veteran's Reiter's syndrome. In the May 2013 Remand, the Board stated that a VA examiner was to identify all joint regions affected by the Veteran's Reiter's syndrome and provide specific information regarding the effect the disability had on those regions. In the June 2013 VA medical examination report procured as a result of the Remand, the VA examiner did not provide the information requested by the Board. Therefore, a Remand for an additional examination is required. Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a VA examination, preferably with a rheumatologist or a physician similarly qualified to respond to the inquiry below, to determine the current severity of his service-connected Reiter's syndrome. The claims folder must be provided to and reviewed by the examiner in conjunction with the requested VA examination. All indicated tests and studies must be performed, and all findings must be set forth in detail. The VA examiner must indicate all present symptoms and manifestations attributable to the Veteran's service-connected Reiter's syndrome, in accordance with 38 C.F.R. § 4.71a , Diagnostic Code 5002 for rheumatoid arthritis, including, as appropriate, under the criteria for when there is an active process. With regard to evaluating chronic residuals of the underlying condition, the VA examiner must identify all affected joint regions. The examiner must then report complete range of motion findings for the affected joint(s). The examiner should specifically indicate whether the limitation of motion was confirmed by findings such as selling, muscle spasm, or other satisfactory evidence of painful motion. The examiner must indicate whether pain or weakness significantly limits functional ability during flare-ups or when the measured area(s) is/are used repeatedly over a period of time. The examiner must also be asked to determine whether the affected joint region(s) exhibits weakened movement, excess fatigability or incoordination. These determinations must be expressed in terms of additional range of motion lost due to any weakened movement, excess fatigability or incoordination. In reviewing the claims folder, the VA examiner should be asked to comment on any identified joints that he or she found were chronically affected by the Veteran's Reiter's syndrome, to include whether those joints affected during the entirety of the increased rating period under appeal, dating back to October 2002. 2. Thereafter, and after undertaking any additional development deemed necessary, readjudicate the issues on appeal. If the benefits sought on appeal remain denied, in whole or in part, the Veteran and his representative must be provided with a Supplemental Statement of the Case and be afforded reasonable opportunity to respond. The case must then be returned to the Board for further appellate review, if otherwise in order. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ VITO A. CLEMENTI Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs