Citation Nr: 1335895 Decision Date: 11/05/13 Archive Date: 11/13/13 DOCKET NO. 07-31 202 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Indianapolis, Indiana THE ISSUE Entitlement to service connection for hypertension, to include as secondary to posttraumatic stress disorder (PTSD). REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Russell P. Veldenz, Counsel INTRODUCTION The Veteran served on active duty from July 1978 to May 1984. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Indianapolis, Indiana, which denied service connection for hypertension on a direct-incurrence basis. A January 2009 rating decision denied service connection for hypertension as secondary to PTSD. In September 2008, the Veteran gave testimony at a hearing before a RO Decision Review Officer regarding the claim for service connection for hypertension. The transcript of such proceeding is in the claims folder. In May 2010, the Veteran testified before the undersigned Veterans Law Judge, and a transcript of that hearing is associated with the claims file. In September 2010 and March 2013, the Board remanded the case to the RO for additional development. As the requested development has been completed, no further action is necessary to comply with the Board's remand directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). FINDINGS OF FACT The most probative evidence of record fails to demonstrate that it is at least as likely as not that the Veteran was diagnosed or treated for hypertension symptoms in service, that hypertension was manifested to a compensable degree within one year from the date of separation from service, that current hypertension is related to an injury or disease or event in service, or that current hypertension is proximately due to or chronically aggravated by service-connected PTSD. CONCLUSION OF LAW Hypertension was not incurred in or aggravated by active service, may not be presumed to have been incurred in or aggravated by service, and is not proximately due to or chronically aggravated by service-connected PTSD. 38 U.S.C.A. §§ 1110, 1112, 5107(b) (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, codified in part at 38 U.S.C.A. §§ 5103, 5103A, and implemented in part at 38 C.F.R § 3.159, amended VA's duties to notify and to assist a claimant in developing information and evidence necessary to substantiate the claims. Duty to Notify Under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b), when VA receives a complete or substantially complete application for benefits, it will notify the claimant of the following: (1) any information and medical or lay evidence that is necessary to substantiate the claim, (2) what portion of the information and evidence VA will obtain, and (3) what portion of the information and evidence the claimant is to provide. The VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). The RO provided pre- adjudication VCAA notice by letters, dated in September 2006 before the rating decision in May 2007 concerning direct service connection and in October 2008 before the rating decision in April 2009 concerning hypertension as secondary to service-connected PTSD. The notices included the type of evidence needed to substantiate the claim of service connection on a direct-incurrence basis, namely, evidence of an injury or disease or event in service; evidence of current disability; and evidence of a relationship between the current disability and the injury or disease or event in service, and included the type of evidence needed to substantiate the claim of service connection as secondary to service-connected PTSD, namely evidence of a current disability, and evidence that the service-connected disability either caused or chronically aggravated the disability at issue for which service connection is sought. The Veteran was notified that VA would obtain service treatment records, VA records, and records from other Federal agencies, and that he could submit other records not in the custody of a Federal agency, such as private medical records, or with his authorization VA would obtain any non-Federal records on his behalf. The notice included the provisions for consideration in the assignment of an effective date and disability rating, in the event of award of the benefit sought. As for content of the VCAA notice, the documents complied with the specific requirements of Quartuccio v. Principi, 16 Vet. App. 183, 186-87 (2002) (identifying evidence to substantiate a claim and the relative duties of VA and the claimant to obtain evidence); of Charles v. Principi, 16 Vet. App. 370, 374 (2002) (identifying the document that satisfies VCAA notice); of Pelegrini v. Principi, 18 Vet. App. 112, 119-120 (2004) (38 C.F.R. § 3.159 notice); and of Dingess v. Nicholson, 19 Vet. App. 473, 484-86 (2006) (notice of the elements of the claim). Duty to Assist Under 38 U.S.C.A. § 5103A, VA must make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claim. The RO has obtained service treatment records, VA records, private medical records, and obtained VA examinations in November 2008, October 2010, and April 2013. He was provided a Board hearing in May 2010 and a DRO hearing in September 2008. The reports of the VA examination included a review of the Veteran's medical history, including his VA treatment records and service records. Further, the examination reports, particularly the April 2013 VA examination report, provided opinions with a basis or rationale for the opinions. Therefore, the Board concludes that the VA opinions are adequate. 38 C.F.R. § 4.2; see Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) recently held that 38 C.F.R. § 3.103(c)(2) (2010) requires that the Veterans Law Judge who conducts a hearing fulfill two duties to comply with the above the 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. Here, during the Board hearing in May 2010, the Veteran was assisted at the hearing by an accredited representative from the Disabled American Veterans. The Veteran Law Judge identified the issues and also clarified for the Veteran what issue was currently before the Board, namely service connection for hypertension but not service connection for obesity. The Veteran replied that he understood. He replied that he had a weight problem in service and understood obesity was a causative factor in hypertension. By this statement, the Veteran expressed understanding for the need to establish a connection between hypertension and an event in service. The representative questioned the Veteran regarding the medical treatment in service and subsequent to separation. The representative and the Veterans Law Judge (VLJ) asked questions to ascertain the treatment at VA and the events in service. The hearing focused on the elements necessary to substantiate the claim, and the Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claim for service connection for hypertension. Therefore, the Board finds that, consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2) by identifying the issue, and to the extent the VLJ did not expressly suggest overlooked evidence pertinent to the hypertension service connection claim, such error is harmless as both the Veteran and representative also demonstrated actual knowledge of what was needed to prove the claim. In addition, the Veteran had a hearing before a Decision Review Officer (DRO) in September 2008. While Bryant decision relates to the VLJ, the provisions of 38 C.F.R. § 3.103(c)(2) require that the decision review officer (DRO) 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. In this hearing, the DRO identified the issue as service connection for hypertension and specifically asked if there was additional evidence that needed to be acquired or presented. He also asked if hypertension was diagnosed in service or within a year after separation and thus soliciting evidence to establish service connection by the presumption afforded under 38 C.F.R. §§ 3.307, 3.309. The hearing also included argument and evidence to support the Veteran's contention that his hypertension is secondary to PTSD. The representative and the DRO asked questions to ascertain the treatment at VA and the events in service. The hearing focused on the elements necessary to substantiate the claim, and the Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claim for service connection for hypertension. Therefore, the Board finds that the DRO complied with the duties set forth in 38 C.F.R. § 3.103(c)(2) by identifying the issue, and suggesting or soliciting evidence as to the missing elements of the claim. To the extent the DRO did not expressly state the elements of the hypertension service connection claim that were lacking to substantiate it, such error is harmless as both the Veteran and representative also demonstrated actual knowledge of what was needed to prove the claim. As the Veteran has not identified any additional evidence pertinent to the claim and as there are no additional records to obtain, the Board concludes that no further assistance to the Veteran in developing the facts pertinent to the claims is required to comply with the duty to assist. Principles of Service Connection Direct incurrence basis Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. § 1110, 38 C.F.R. § 3.303. Generally, to establish service connection on a direct incurrence basis, a Veteran must show: (1) a present disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. All three elements must be proved. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service, or if preexisting such service, was aggravated by service. This may be accomplished by showing inception or aggravation during service. 38 C.F.R. § 3.303(a). Service connection may be established by continuity of symptomatology after service under 38 C.F.R. § 3.303(b). The Federal Circuit recently held that continuity of symptomatology under § 3.303(b) applies only to the chronic diseases that are listed in § 3.309. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). Hypertension, as a cardiovascular-renal disease, is listed as a disease under § 3.309 as a chronic disease. The showing of a chronic disease, such as hypertension, in service requires 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." Continuity of symptomatology after discharge is required where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. 38 C.F.R. § 3.303(b). For a Veteran who served 90 days or more of active service after December 31, 1946, there is a presumption of service connection for certain disabilities such as hypertension if the disability is manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. § 1112; 38 C.F.R. §§ 3.307, 3.309. 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). Secondary to service-connected disability Disability which is proximately due to, or aggravated by, a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310. Evidentiary Standards VA must give due consideration to all pertinent lay and medical evidence in a case where a Veteran is seeking service connection. 38 U.S.C.A. § 1154(a). Competency is a legal concept in determining whether lay or medical evidence may be considered, in other words, whether the evidence is admissible as distinguished from credibility and weight, factual determinations going to the probative value of the evidence, that is, does the evidence tend to prove a fact, once the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997). 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. 38 C.F.R. § 3.159. Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer a medical diagnosis, statement, or opinion. 38 C.F.R. § 3.159. Competency is a question of fact, which is to be addressed by the Board. Jandreau, v. Nicholson, 492 F.3d 1372, 1377 (2007). When the evidence is admissible, the Board must then determine whether the evidence is credible. "Credible evidence" is that which is plausible or capable of being believed. See Caluza v. Brown, 7 Vet. App. 478, 511 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (the determination of credibility is a finding of fact to be made by the Board in the first instance). If the evidence is credible, the Board, as fact finder, must determine the probative value or weight of the admissible evidence, that is, does the evidence tend to prove a material fact. Washington v. Nicholson, 19 Vet. App. 362, 369 (2005). If the evidence is not credible, the evidence has no probative value. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the Veteran. 38 U.S.C.A. § 5107(b). Facts As noted, the Veteran served from July 1978 to May 1984. The Veteran has testified and his DD-214 also establishes that the Veteran served as a military police officer (MP). The Veteran has also testified that in February 1981 he was assaulted. As a result of this assault, the Veteran has been service connected for PTSD. The Board notes that although there are service treatment records, they do not appear to be complete. For instance, the separation examination does not appear to be of record. The entrance examination is part of the record before the Board and the blood pressure was 134/68. In February 1981, the Veteran had a blood pressure of 138/74. It was noted that the Veteran had been in a fight, and this was later identified by the Veteran as the incident where he was assaulted. In May 1981, in what was described as a separation physical, the blood pressure was 140/94 and the notes indicate the Veteran was to have 3 days of blood pressure readings in the morning and the evening sitting, standing, and lying down. No such follow up appears in the record. In May 1983, the Veteran's blood pressure was 158/77. That same month, the Veteran was evaluated by service medical personnel for exceeding the Army's weight guidelines. In June 1983, his blood pressure was 104/70. In August 1985, the Veteran was again evaluated by service medical personnel for exceeding the Army's weight guidelines. In March 1988, in an enlistment physical for the United States Army National Guard, his blood pressure was 130/77. In the history, the Veteran stated he did not have a history of high blood pressure. It appears the Veteran started seeking treatment from VAMC starting in September 2003. At that time, his blood pressure was 130/84 but by November 2003, the blood pressure reading was called elevated at 140/92. The Veteran then was tested for blood pressure levels on several occasions in December 2003 with a reading on one occasion of 152/89 in the left arm and 132/72 in the right arm. On another occasion in December 2003, he had a reading of 140/82 but after resting, the blood pressure reading was 132/82. He was also described as morbidly obese. The Veteran continued to have elevated blood pressure readings with 140/70 noted in January 2004, 140/70 in February 2004, 132/80 and 130/86 in July 2004 and 149/82 in February 2005. In March 2005, the Veteran sought emergency room treatment as he complained of headaches, dizziness, and nausea. The blood pressure reading was 186/98 while sitting and 164/104 while standing although the Veteran complained of feeling lightheaded while standing or walking. It was noted he had not been taking antihypertensive medication. He was given medication and his blood pressure reading was 126/76. At that time, the Veteran was diagnosed with hypertension and since that time, he has been taking medication and followed by VA care providers. In October 2008, the Veteran submitted a statement from Dr. J. C. Satori, a psychiatrist, who stated the Veteran reported military records documenting hypertension after the assault in February 1981. Dr. Satori stated that PTSD is an anxiety disorder involving changes to the autonomic nervous system and concluded that it was at least as likely as not that the Veteran's hypertension was a direct result of the Veteran's documented PTSD. The Veteran was provided three VA examinations in November 2008. The first, a medical examination, noted the Veteran was diagnosed with hypertension two and a half years earlier. It was noted that the course since diagnosis had been progressively worse although he had not been hospitalized due to hypertension, nor had he developed any associated symptoms such as hypertensive renal disease, headaches, hypertensive cardiovascular disease or strokes. The Veteran was not sure if he had chest pains and reported what he felt was indigestion. He reported daily fatigue and dizziness and dyspnea upon mild exertion. The blood pressure readings were 140/70, 145/73, and 143/63. The physical examination did not reveal any abnormalities. The examiner noted the Veteran had a stress test in October 2008 suggestive of lateral ischemia and he was off work because of the results. The Veteran worked as a VA police officer. The Veteran also described short term memory loss which the Veteran attributed to hypertension. The diagnosis was hypertension. The examiner stated, however, that it was not possible to determine whether the Veteran's PTSD caused his hypertension without recourse to speculation. The examiner noted that the literature does indicate a high level of stress, obesity, and certain lines of work such as his work as a police officer may predispose a person to hypertension. It was further stated that the Veteran also had hyperlipidemia which also causes blood pressure elevation and "PTSD is a known stressor and can cause hypertension." The examiner continued that, if the PTSD did not cause the hypertension, it can most certainly aggravate hypertension. The examiner could not find any elevated blood pressure readings or diagnosis of hypertension before 2003. The examiner also noted the Veteran was about 100 pounds overweight and that obesity increases the risk of hypertension. It was concluded that, based upon the available information, the hypertension in the Veteran was multifactorial in nature and maybe due to lifestyle (specifically his job), hyperlipidemia, stressors such as PTSD, and obesity. This lead to the conclusion that it would be speculative as to opine whether PTSD caused the hypertension. The second VA examination was a PTSD examination. The examiner confirmed the Veteran has a diagnosis of PTSD and detailed the symptoms which occurred daily at a moderate level. This includes moments of panic and hyperalertness. He experiences rage and guilt over the military assault. The GAF was 52. The examiner stated he had not reviewed the service treatment records. He also stated while it is possible that the Veteran's PTSD could result in a rise in blood pressure, there is no way to determine the result without recourse to sheer speculation whether PTSD caused the Veteran's hypertension as it could have any number of causes. In the third VA examination, the VA examiner opined that it was possible that PTSD could have contributed to the Veteran's hypertension but this possibility was based upon speculation as there were numerous possible etiologies for hypertension. The examiner acknowledged that PTSD is an anxiety disorder and current literature suggested experienced anxiety can affect the autonomic system, which may elevate blood pressure and heart rate. It was noted that hypertension is a chronic elevation of blood pressure which is based on many factors, psychological and medical/physiological, other than anxiety. Therefore, the examiner concluded it was impossible to determine the etiology of the Veteran's current hypertension without resorting to mere speculation. A VA examination occurred in October 2010. The VA examiner reviewed the Veteran's service treatment records and VA treatment records and diagnosed essential hypertension. He noted it was diagnosed after the Veteran experienced dizziness at work. It was noted that the course since diagnosis had been stable. It was further indicated that, other than dizziness, there were no associated symptoms such as hypertensive renal disease, headaches, hypertensive cardiovascular disease or strokes. The blood pressure readings were 128/64, 126/84, and 129/65. The VA examiner also found that it was at least as likely as not that the Veteran's hypertension was permanently aggravated by weight gain. The VA examiner reported that obesity was a well-known factor for the development of essential hypertension. However, because essential hypertension was a multifactorial disease with many established and unknown contributing factors, the VA examiner could not state to what extent the Veteran's obesity had aggravated his hypertension. With respect to the findings of elevated blood pressure in the service treatment records, the VA examiner opined that the Veteran's hypertension was less likely as not caused by or the result of any findings of elevated blood pressure in service because one reading of elevated blood pressure did not establish a diagnosis of hypertension. The VA examiner also focused on the diagnosis of hypertension in 2004 with only one recording of high blood pressure almost 30 years earlier in service. With respect to a nexus between the Veteran's hypertension and his service-connected PTSD, it was opined the Veteran had essential hypertension, which was not caused by PTSD. The examiner did not give a reason for the conclusion that the Veteran's hypertension was not caused by or the result of the PTSD. In April 2013, the Veteran was given a VA examination and the examiner reviewed the file. The blood pressure readings at the VA examination were 148/80, 130/90, and 148/85. The examiner noted various blood pressure readings in the service treatment records such as the one taken the date of the assault (138/74). He also noted that after a reading of 140/94 was recorded in May 1981, there was a plan for a follow-up but no follow up notes were found. The examiner concluded that the May 1981 blood pressure was an isolated elevated blood pressure reading and normal blood pressures were noted afterwards even more than 20 years later. It was noted that the Veteran had not been diagnosed with hypertension until 2004. The examiner concluded that the May 1981 elevated blood pressure was not related to the current hypertension and hypertension was not incurred in or caused by an in-service event, injury, or illness. As to PTSD causing or aggravating the hypertension, the examiner noted that there is not a consistent body of medical literature to indicate a causal relationship between hypertension and PTSD. The examiner stated that, as the standard requires a causal connection be shown, it was concluded that the Veteran's diagnosis of hypertension is not related to his PTSD and is more likely essential hypertension. Noting a family history of hypertension, the examiner concluded that there are genetic as well as life-style factors that resulted in the diagnosis of hypertension. The examiner also stated that he reviewed the Veteran's current and past medications and their side effects and there is no indication the medications for PTSD would aggravate hypertension. Finally, as the Veteran attributed his weight gain to PTSD and the weight gain in turn contributed to the hypertension, the examiner stated it is less likely than not that PTSD caused or aggravated the Veteran's weight gain. It is more likely related to behaviors and choices made by the Veteran. The Veteran's Lay Evidence As noted, as a lay person, the Veteran is competent to describe symptoms, which he is able to perceive through the use of his senses. 38 C.F.R. § 3.159 (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.); see Layno v. Brown, 6 Vet. App. 465, 469-71 (1994) (lay testimony is competent as to symptoms of an injury or illness, which are within the realm of one's personal knowledge, personal knowledge is that which comes to the witness through the use of the senses). Further, the Veteran's statements and testimony are admissible and are to be considered as evidence of continuity. Rucker v. Brown, 10 Vet. App. 67, 74 (1997) (Competency is a legal concept in determining whether lay evidence may be considered, in other words, whether the evidence is admissible). The Board thus finds that the Veteran is competent to describe his symptoms and events regarding high blood pressure or hypertension in service and thereafter. Although the Veteran is competent to describe symptoms of hypertension, unless the diagnosis is capable of lay observation, the determination as to the presence or diagnosis of such a disability is medical in nature and competent medical evidence is required to substantiate the claim. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007) (Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation). The Veteran is not asserting any condition that is capable of lay observation. See Jandreau, 492 F.3d at 1377 (explaining in a footnote, sometimes a 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); see also Barr, 21 Vet. App at 309 (varicose veins were subject to non-expert diagnosis due to the readily observable defining characteristics of the condition). A diagnosis of hypertension cannot be made by the Veteran as a lay person based on visual observation or by any other of the senses. As demonstrated by this case, a diagnosis depends upon interpretation of symptoms, and clinical and diagnostic tests, such as blood pressure readings, which requires medical knowledge. No factual foundation has been established that the Veteran is otherwise qualified through specialized education, training, or experience to offer a medical diagnosis or to offer an opinion on the questions of etiology. Therefore, the Veteran's assertion or opinion that he has hypertension and the relationship of hypertension to service is not competent evidence. To this extent his statements and testimony are not admissible as evidence of the diagnosis and causation of a disability. It is the opinion of a layman and not competent medical evidence of a diagnosis by a medical professional. The Veteran's discussion of his symptoms certainly is important, however, the Veteran's opinion as to the cause of his symptoms cannot outweigh the opinion of a medical professional. To sum up the foregoing, the Board will consider the Veteran's testimony as it relates to the onset and continued presence of his symptoms. Such lay evidence is relevant and competent. To the extent that the Veteran is offering his own opinion as to what disability is causing the symptoms, or the relationship of the disability to service, the Board has disregarded the Veteran's opinions in its analysis. Analysis The medical community has defined hypertension as high arterial blood pressure with a minimum threshold of 140 mm for systolic blood pressure and 90 mm for diastolic blood pressure. See Duenas v. Principi, 18 Vet. App. 512, 520 (2004) (citing Dorland's Illustrated Medical Dictionary, 801 (28th ed. 1994).) The Board notes, however, that the service treatment records do not show a diagnosis of hypertension or treatment, including prescriptions, and all readings of blood pressure in service were normal with two exceptions, May 1981 (140/94) and May 1983 (158/77). In neither instance did the service providers diagnose hypertension and the two readings appear to be isolated elevated readings and not indicative of a chronic condition such as hypertension. Furthermore, the Veteran had normal blood pressure readings after these two readings. In addition, although serial readings were planned, the serial readings did not occur. Based on the discussion of the experts and evidence noted above, it appears serial blood pressure readings are needed for a diagnosis of hypertension. The Board notes that VA requires serial blood pressure readings for the diagnosis of hypertension. See 38 C.F.R. § 4.104, Diagnostic Code 7101, Note (1). As there is no other evidence demonstrating hypertension while in service, the Board finds that hypertension was not present during the period of active service and service connection may not be granted under 38 C.F.R. § 3.303(a). In addition, there is no medical evidence of hypertension being diagnosed and treated to a compensable degree within one year of separation. The Board therefore finds that the presumption of service connection does not apply to the Veteran's claim for service connection for hypertension as it did not manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. § 1112; 38 C.F.R. §§ 3.307, 3.309. That still leaves open the question whether the most probative evidence of record establishes that it is at least as likely as not that hypertension was incurred in service, or is the result of or aggravated by the Veteran's service connected PTSD. As noted above, the Board has disregarded the Veteran's lay opinion that his hypertension is related to service and turns to whether there is any competent medical evidence that establishes a nexus between the Veteran's hypertension and service. While the Veteran's report of symptoms he experienced are relevant, competent, and credible, this evidence does not establish the nexus to service by itself, but rather, are facts that someone with medical knowledge can consider as to the relationship between hypertension and service. As to the Veteran's report of what he was told by physicians in service and after, the Court has previously noted, the connection between what a physician said and the layman's account of what he purportedly said, filtered as it was through a layman's sensibilities, is simply too attenuated and inherently unreliable to constitute 'medical' evidence. Robinette v. Brown, 8 Vet. App. 69, 77 (1995); see also Marciniak v. Brown, 10 Vet. App. 198 (1997). The Board finds that the only competent and credible medical evidence before the Board, as to the claim of service connection for hypertension are the reports of Dr. Satori and the VA examiners. All are qualified by education, training, or experience to diagnose a medical condition and to offer an opinion on causation. With regard to medical opinions, the probative value or evidentiary weight to be attached to a medical opinion is within the Board's province as finder of fact. The guiding factors in evaluating the probative value of a medical opinion include whether the opinion applied valid medical analysis to the significant facts of the case in order to reach the conclusion submitted in the opinion. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302 -03 (2008). Dr. Satori's opinion is based upon the Veteran's history which indicated hypertension was diagnosed in service. It does not appear that Dr. Satori reviewed the available service treatment records. Those records do not reveal any hypertension diagnosis and only a few elevated blood pressure readings, which as noted above, are insufficient to make a diagnosis of hypertension. Swann v. Brown, 5 Vet. App. 229, 233 (1993) (the Board may reject a medical opinion because other facts present in the record contradict the facts provided by the veteran that formed the basis for the opinion); Bardwell v. Shinseki, 24 Vet. App. 36, 40 (2010) (holding that a layperson's assertions indicating exposure to gases or chemicals during service are not sufficient evidence alone to establish that such an event actually occurred during service). See also Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that the Board may reject a medical opinion that is based on facts provided by the veteran that have previously been found to be inaccurate). He thus appears to have formed an opinion based upon an incomplete or inaccurate understanding of the facts. Thus, Dr. Satori's opinion is not entitled to probative weight as there is no indication he reviewed all of the medical evidence in the file. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). In addition, he associates PTSD with hypertension because anxiety disorders can raise blood pressure. He does not discuss what has been noted by the November 2008 examiner. That examiner noted the elevation in blood pressure occurs with the onset of the anxiety and does not account for a chronic disorder such as hypertension. Stated another way, once the anxiety stops, the blood pressure apparently does not remain elevated, but hypertension, as a chronic condition, results in continued elevated blood pressure. Thus, for all of the foregoing reasons, the Board places less probative weight upon Dr. S's opinion as it is conclusory, lack persuasive reasoning and does not take into account all of the pertinent evidence of record. As to the November 2008 VA examiners, these examiners concluded it would be speculative to opine as to whether hypertension was related to service as causation of hypertension is multifactoral. Service connection may not be based on a resort to speculation or remote possibility. 38 C.F.R. § 3.102. See Morris v. West, 13 Vet. App. 94, 97 (1999) (diagnosis that appellant was "possibly" suffering from a disability was deemed speculative); Bloom v. West, 12 Vet. App. 185, 186-87 (1999) (treating physician's opinion that service "could have" precipitated disability found too speculative). Further, the PTSD examiner had not reviewed the available service treatment records, and the other VA examiner overlooked and therefore did not account for the elevated blood pressure readings in service. Nevertheless, to the extent that the VA examiners discussed medical knowledge such as hypertension is not based upon an isolated reading, as this same proposition is relied upon by the April 2013 VA examiner, the opinions do have slight probative value upon their reports as that information is relevant, consistent with subsequent medical opinions, and helps inform the Board in making its decision. As to the October 2010 VA examiner's opinion, at first blush it appears that the examiner's opinion is favorable to the Veteran when he concluded that the Veteran's hypertension was permanently aggravated by weight gain. Further, the examiner stated the Veteran's hypertension was a multifactorial disease with many established and unknown contributing factors, the VA examiner could not state to what extent the Veteran's obesity had aggravated his hypertension. In this respect, the Board notes that obesity is a manifestation and not a disability warranting service connection. Service connection may be warranted on the basis of a relationship between hypertension and weight gain only if the Veteran's weight gain is found to be caused or aggravated by his service-connected PTSD. The examiner concluded without explanation, however, that the PTSD did not cause or aggravate the hypertension. As this opinion is a conclusory statement given without supporting data or reasoning, the Board finds the opinions to be of little probative value. See Nieves- Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (stating that a medical opinion must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions). The Board finds that the opinion of the April 2013VA examiner is more probative as to the claim of service connection for hypertension than the foregoing opinions. The Board finds the unfavorable medical opinion of the April 2013 VA examiner is well reasoned, detailed, and provides a rationale that is consistent with other evidence of record, and included reviews of the claims file and the Veteran's symptoms. The examiner noted the elevated blood pressure readings in service and even the plan in May 1981 to follow up with further readings but there was no apparent follow up. It was also noted that the elevated blood pressures were isolated and that the Veteran had normal readings for many years after. The VA examiner set forth an accurate historical history with medical details taken from the Veteran's claims file, which renders it especially probative. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion). The examiner applied medical literature to support his conclusions that the medical literature is either inconclusive or has not established a relationship between for example PTSD and obesity. Finally, the examiner accounted for other non-service related factors that could explain the Veteran's hypertension such as genetics and the Veteran's life style factors since service. As the VA examiner applied medical analysis to the significant facts of the case to reach the conclusion expressed in the opinion, the Board also finds the evidence competent and credible and highly probative on the material issues of fact, i.e., whether hypertension is related to service. The VA examiner has provided the most probative evidence and the Board assigns it the most weight as the examiner's report specifically addresses the question of a diagnosis and its relationship to service. Finally, the Board acknowledges the Veteran's service organization representative has cited medical articles associating PTSD with certain medical conditions but the medical conditions named are heart diseases such as coronary artery disease and not hypertension. Therefore, they have no relevance to the Veteran's case as service connection for hypertension is the only claim before the Board. Further, the articles do not appear to address the pertinent facts in the Veteran's individual case, and were not referenced in any supporting medical evidence in the Veteran's record. See Sacks v. West, 11 Vet. App. 314, 316-17 (1998) (holding that a medical article or treatise can provide support for a claim, but must be combined with an opinion of a medical professional and be reflective of the specific facts of a case as opposed to a discussion of generic relationships); Libertine v. Brown, 9 Vet. App. 521, 523 (1996) (finding that generic medical literature which does not apply medical principles regarding causation or etiology to the facts of an individual case does not provide competent evidence to establish a nexus between current disability and military service). Thus, the Board finds that the articles do not have any probative value as to the question of a nexus between service and the Veteran's hypertension. In sum, the Board finds that the opinion of the April 2013 VA examiner is the most persuasive evidence of record and this weighs against the Veteran's claim. Accordingly, the weight of the medical evidence is against an association or link between hypertension and service, or service-connected PTSD. The preponderance of the competent probative evidence is against the claim of service connection on the applicable theories of service connection, and the benefit of-the-doubt standard of proof does not apply. 38 U.S.C.A. § 5107(b) ORDER Entitlement to service connection for hypertension, to include as secondary to PTSD, is denied. ____________________________________________ U. R. POWELL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs