Citation Nr: 1513640 Decision Date: 03/31/15 Archive Date: 04/03/15 DOCKET NO. 09-19 776 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to service connection for right ear hearing loss. 2. Entitlement to service connection for a right shoulder condition. 3. Entitlement to service connection for a right elbow condition. 4. Entitlement to service connection for a prostate condition. 5. Entitlement to service connection for residuals of a stab wound to the chest. 6. Entitlement to service connection for hypertension. 7. Entitlement to service connection for a heart condition with aortic valve repair. 8. Entitlement to higher ratings for residuals fracture of distal fibula left ankle, an initial rating in excess of 10 percent from April 28, 2006, to September 8, 2009, and a rating in excess of 20 percent from September 9, 2009, forward. 9. Entitlement to higher ratings for degenerative disc disease L4 5 and L5-S1, an initial rating in excess of 20 percent, from April 28, 2006, to September 8, 2009, and a rating in excess of 40 percent from September 9, 2009, forward. 10. Entitlement to compensation benefits, pursuant to the provisions of 38 U.S.C.A. §1151, for a chronic obstructive pulmonary disorder (COPD) exacerbation, claimed to have resulted from treatment at a VA Medical Center (VAMC). REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Jeanne Schlegel, Counsel INTRODUCTION The Veteran had active military service from December 6, 1983 to December 5, 1986, under honorable conditions. His period of service from December 6, 1986 to June 16, 1989 was under dishonorable conditions and is not therefore qualifying active service for VA purposes. An unappealed administrative decision to this effect was issued in November 2006. This appeal to the Board of Veterans' Appeals (Board) arose from a September 2007 rating decision in which the RO denied service connection claims (1) through (7), as listed on the title page, but granted service connection for degenerative disc disease L4 5 and L5-S1 (a low back disability) and for residuals fracture of distal fibula left ankle (a left ankle disability), which were assigned initial ratings of 20 and 10 percent, respectively, each effective April 28, 2006. The Veteran filed a notice of disagreement in September 2007. A statement of the case was issued in March 2009 and the Veteran perfected his appeal with the filing of a substantive appeal in April 2009. Later, in a December 2013 rating decision, higher 20 and 40 percent ratings were granted for left ankle and low back disabilities, respectively, each effective September 9, 2009. Supplemental Statements of the Case (SSOCs) were issued in January 2014. Although the RO granted higher ratings for the left ankle and low back disabilities from September 9, 2009, as higher ratings are available from disability before and after that date, and a veteran is presumed to seek the maximum available benefit for a disability, the Board has recharacterized the claims for higher ratings-which reflect the initial and subsequent staged ratings currently assigned-as reflected on the title page. See Fenderson v. West, 12 Vet. App. 119 (1999); AB v. Brown, 6 Vet. App. 35 (1993). This appeal also arose from a September 2010 rating decision in which the RO denied entitlement to compensation benefits, pursuant to the provisions of 38 U.S.C.A. §1151, for a COPD exacerbation, claimed to have resulted from treatment at a VAMC. The Veteran filed a notice of disagreement in September 2010. A statement of the case was issued in January 2012 and the Veteran perfected his appeal with the filing of a substantive appeal in January 2012. An SSOC was issued in January 2014. In February 2014, the Veteran signed a statement indicating that he was not satisfied with the decision regarding his appeals and waived the 30-day waiting period following the issuance of the SSOCs so that the case could be immediately forwarded to the Board for a decision. In September 2014, the Veteran presented testimony during a Board video conference hearing held before the undersigned Veterans Law Judge. A transcript of that hearing is of record. As reflected in the Board hearing transcript, and as documented in a September 2014 written statement, the Veteran has elected to withdraw from appeal service connection claims for: right ear hearing loss; a right shoulder condition; a right elbow condition; a prostate condition; and for residuals of a stab wound to the chest. Accordingly, those claims will be formally dismissed below. This appeal has been processed utilizing the paperless, electronic Virtual VA and Veteran Benefits Management System (VBMS) claims processing systems.. The Board's dismissal of the withdrawn claims, and the decision on the service connection claims for hypertension and a heart condition is set forth below. The remaining claims on appeal are addressed in the Remand following the Order; these matters are being remanded to the agency of original jurisdiction (AOJ). VA will notify the Veteran when further action, on his part, is required. FINDINGS OF FACT 1. In September 2014, prior to the promulgation of a decision by the Board, the Veteran withdrew from appellate consideration service connection claims for: right ear hearing loss; a right shoulder condition; a right elbow condition; a prostate condition; and for residuals of a stab wound to the chest. 2. All notification and development actions needed to fairly adjudicate each claim herein decided have been accomplished. 3. The Veteran's service from December 6, 1986 to June 16, 1989 was under dishonorable conditions and is not therefore qualifying active service for VA purposes. Entitlement to service connection for hypertension or a heart condition based on that period of service is precluded as a matter of law. 4. Hypertension was not manifested during the Veteran's period of honorable service from December 6, 1983 to December 5, 1986, and is not shown to be otherwise etiologically related to this period of active duty service. 5. A heart condition with aortic valve repair was initially diagnosed more than a decade after the Veteran's discharge from service, and there has been no demonstration by competent and credible evidence of record that this condition is causally related to active service or to a service-connected disability. 6. As service connection is not in effect for hypertension, a claim for service connection for a heart condition with aortic valve repair as secondary to such disease is not a viable theory of entitlement. CONCLUSIONS OF LAW 1. The criteria for withdrawal of a substantive appeal relating to the service connection claims for right ear hearing loss, a right shoulder condition, a right elbow condition, a prostate condition, and residuals of a stab wound to the chest are met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2014); 38 C.F.R. §§ 20.202, 20.204 (2014). 2. The Veteran's service from December 6, 1986 to June 16, 1989 was dishonorable for VA compensation purposes and resultantly a bar to VA benefits (exclusive of certain health care) based on that period of service. 38 U.S.C.A. §§ 101(2), 5303 (West 2014); 38 C.F.R. §§ 3.12, 3.13 (2014). 3. The criteria for service connection for hypertension, for the period of active service from December 6, 1983 to December 5, 1986, are not met. 38 U.S.C.A. §§ 1131, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2014). 4. The criteria for service connection for a heart condition with aortic valve repair, to include as secondary to hypertension, are not met. 38 U.S.C.A. §§ 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2014). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Dismissal of Service Connection Claims Under 38 U.S.C.A. § 7105, the Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. A substantive appeal may be withdrawn in writing at any time before the Board promulgates a decision. 38 C.F.R. § 20.202. Withdrawal may be made by the appellant or by his or her authorized representative. 38 C.F.R. § 20.204. In a rating action issued in September 2007, the RO denied service connection claims for right ear hearing loss; a right shoulder condition; a right elbow condition; a prostate condition; and for residuals of a stab wound to the chest. A timely NOD was filed in September 2007. A statement of the case was issued in March 2009 and the Veteran perfected his appeal with the filing of a substantive appeal in April 2009, giving appellate status to the claims. In a September 2014 statement from the Veteran's representative, it was requested that the aforementioned service connection claims be withdrawn from appellate consideration, per the Veteran's request. The same information was documented as shown in the September 2014 Board hearing transcript. Therefore, no allegations of errors of fact or law remain for appellate consideration with respect to the service connection claims for right ear hearing loss, a right shoulder condition, a right elbow condition, a prostate condition, and residuals of a stab wound to the chest. Accordingly, the Board does not have jurisdiction to review the appeal with respect to the aforementioned claims and they must be dismissed. II. Due Process Considerations for Claims Decided The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2014)) includes enhanced duties to notify and assist claimants for VA benefits. VA regulations implementing the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2014). Notice requirements under the VCAA essentially require VA to notify a claimant of any evidence that is necessary to substantiate the claim(s), as well as the evidence that VA will attempt to obtain and which evidence he or she is responsible for providing. See, e.g., Quartuccio v. Principi, 16 Vet. App. 183 (2002) (addressing the duties imposed by 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b)). As delineated in Pelegrini v. Principi, 18 Vet. App. 112 (2004), after a substantially complete application for benefits is received, proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim(s); (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) must ask the claimant to provide any evidence in her or his possession that pertains to the claim(s), in accordance with 38 C.F.R. § 3.159(b)(1) . Effective May 30, 2008, 38 C.F.R. § 3.159 was revised, in part. See 73 Fed. Reg. 23,353 -23,356 (April 30, 2008). Notably, the final rule removed the third sentence of 38 C.F.R. § 3.159(b)(1), which had stated that VA will request that a claimant provide any pertinent evidence in his or her possession. VA's notice requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between service and a claimed disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA-compliant notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the AOJ (in this case, the RO, to include the AMC). Id.; Pelegrini, 18 Vet. App. at 112. See also Disabled American Veterans v. Secretary of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003). However, the VCAA notice requirements may, nonetheless, be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Id. In this appeal, duty to assist letters were issued in November 2006 and September 2008, before and after the initial adjudication of the claims in September 2007. These letters provided notice to the Veteran explaining what information and evidence was needed to substantiate the claims, what information and evidence must be submitted by the appellant, and what information and evidence would be obtained by VA. The November 2006 letter also included information pertaining to the assignment of disability ratings and effective dates, as well as the type of evidence that impacts those determinations. Since providing these notice letters, the AOJ has readjudicated all of the claims on appeal in Supplemental SOCs issued in January 2014. As a result of this readjudication, any timing defect in the provision of this notice has been rectified ("cured"). See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007); (Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). The record also reflects that VA has made reasonable efforts to obtain or to assist in obtaining all relevant records pertinent to the matter herein decided. Pertinent medical evidence associated with the claims file consists of service treatment records (STRs), service personnel records (SPRs), VA records, private medical records and VA/QTC examination reports. Also of record and considered in connection with this matter is the transcript of the Veteran's 2014 Board hearing, along with various written documents provided by the Veteran, and by his representative on his behalf (along with copious amounts of documentary evidence). The Board finds that no additional RO action to further develop the record on his claims, prior to appellate consideration, is required. Specifically as regards the Veteran's September 2014 Board hearing, he was provided an opportunity to set forth his contentions during a hearing before the undersigned Veterans Law Judge. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 3.103(c)(2) requires that the Decision Review Officer or Veterans Law Judge who chairs a hearing to fulfill two duties: (1) to fully explain the issues and (2) to suggest the submission of evidence that may have been overlooked. In this case, the Board finds that there has been compliance with the duties set forth in 38 C.F.R. § 3.103(c)(2), and that the hearing is legally sufficient. Here, during the 2014 hearing, the undersigned noted the issues on appeal. Information was solicited regarding the Veteran's in-service history of relevant incidents, injuries and symptoms and his post-service clinical history and report of symptoms. Therefore, not only were the issues "explained . . . in terms of the scope of the claim for benefits," but "the outstanding issues material to substantiating the claim," were also fully explained. See Bryant, 23 Vet. App. at 497. In addition, the VLJ sought to identify any pertinent evidence not currently associated with the claims file that might have been overlooked or was outstanding that might substantiate the claims. It is noteworthy that neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2) nor has identified any prejudice in the conduct of the VLJ hearing. Moreover, the Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claims for benefits. As such, the Board finds that, consistent with Bryant, the undersigned complied with the duties set forth in 38 C.F.R. § 3.103(c)(2), and that hearing is thus legally sufficient. VA's duty to assist includes obtaining an examination and medical opinion when necessary to make an adequate determination. See Duenas v. Principi, 18 Vet. App. 512 (2004). In this case, examinations for VA purposes were conducted in 2009, 2012, and 2013. The Veteran and his representative have not alleged that any of these examinations were inadequate. See Sickels v. Shinseki, 643 F.3d 1362 (Fed. Cir. 2011) (in the absence of a challenge to the adequacy of the examination, the Board is not required to explicitly explain why each medical opinion is adequate). In summary, the duties imposed by the VCAA have been considered and satisfied. The Veteran has been notified and made aware of the evidence needed to substantiate his claims, the avenues through which he might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. There is no additional notice that should be provided, nor is there any indication that there is additional existing evidence to obtain or development required to create any additional evidence to be considered in connection with this claim. Consequently, any error in the sequence of events or content of the notice is not shown to prejudice the Veteran or to have any effect on the appeal. Any such error is deemed harmless and does not preclude appellate consideration of the matter on appeal, at this juncture. See Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006) (rejecting the argument that the Board lacks authority to consider harmless error). See also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). III. Service Connection The Veteran maintains that service connection is warranted for hypertension and a heart condition with aortic valve repair. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303. Service connection may be granted for any disease diagnosed after discharge from service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Generally, in order to prevail on the issue of service connection, there must be (1) evidence of a current disability; (2) medical evidence, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and (3) evidence of a nexus between an in-service injury or disease and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). Service connection may be presumed, for certain chronic diseases, such as hypertension and cardiovascular-renal disease, which develop to a compensable degree within a prescribed period after discharge from service (one year for hypertension), although there is no evidence of such disease during the period of service. This presumption is rebuttable by probative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Also, while the disease need not be diagnosed within the presumptive period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree. 38 C.F.R. § 3.307(c). With chronic disease shown as such in service (or within the presumptive period under § 3.307) so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributed to intercurrent causes. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is questioned. When the fact of chronicity in service is not adequately supported, then the showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). The United States Court of Appeals for the Federal Circuit recently clarified that the law providing for awards of service connection on the basis of continuity of symptomatology is limited to "chronic" diseases (such as arthritis) listed under 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When there is an approximate balance in the evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the United States. Court of Appeals for Veterans Claims (then, the U.S. Court of Veterans Appeals) (Court) held that that an appellant need only demonstrate that there is an "approximate balance of positive and negative evidence" in order to prevail. The Court has also stated, "It is clear that to deny a claim on its merits, the evidence must preponderate against the claim." Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert. A. Preliminary Matter - Character of Discharge The term "Veteran" means a person who served in the active military, naval, or air service, and who was discharged or released there from under conditions other than dishonorable. 38 U.S.C.A. § 101(2) (West 2002); 38 C.F.R. § 3.1(d) (2014). A discharge or release from active service under conditions other than dishonorable is a prerequisite to entitlement to VA pension or compensation benefits. 38 U.S.C.A. § 101(18); 38 C.F.R. § 3.12(a) (2014). The designation of a discharge by the service department is binding on VA as to character of discharge. 38 C.F.R. § 3.12(a). Except as provided in 38 C.F.R. § 3.13(c), the entire period of service constitutes one period of service, and entitlement will be determined by the character of the final termination of such period of service. See 38 C.F.R. § 3.13(b). There are two types of character of discharge bars to establishing entitlement for VA benefits: (1) statutory bars found at 38 U.S.C.A. § 5303(a) and 38 C.F.R. § 3.12(c); and (2) regulatory bars listed in 38 C.F.R. § 3.12(d). Benefits are not payable for a period of service when a former service member was discharged or released by reason of the sentence of a general court-martial. 38 C.F.R. § 3.12(c)(2). 38 C.F.R. § 3.12(c) In a November 2006 administrative decision, VA determined that the Veteran's service from December 6. 1983 to December 5, 1986, was honorable for VA purposes. December 5, 1986, represents the termination date of a period of reenlistment; and was the date on which the Veteran could have separated after having completed his service commitment, had he not elected to re-enlist. The period from December 6, 1986 to June 16, 1989, however, represented a new period of enlistment. During that period, the Veteran was found guilty of violating numerous provisions of the Uniform Code of Military Justice (UCMJ) to include Articles 92, 111 (operating a vehicle while unpaired by alcohol), and 112a (wrongful use of drugs). A May 1989 court martial order reflects that the disciplinary actions associated with these offenses included dishonorable discharge and confinement for 42 months. The Veteran was notified of VA's decision in November 2006 and did not timely challenge or appeal it. Accordingly, for purposes of this decision, the dishonorable discharge for the period of service from December 6, 1986 to June 16, 1989, is a bar to VA benefits for that period of service. B. Service Connection for Hypertension The STRs include a January 1983 enlistment examination report that revealed that clinical evaluation of the lungs, chest and heart was normal and that a blood pressure reading of 122/86 was made. The Veteran's blood pressure was noted as being 126/90 in May 1985, while the Veteran was being treated for back pain. A reading of 124/90 was made in March 1987, and a reading of 126/94 was made in May 1987. On separation examination of February 1988, blood pressure was 130/92. Private medical records of from the Beth Israel Medical Center reflect that a history of hypertension was noted in 2000 and that hypertension was clinically assessed at least as early as 2001. A QTC examination was conducted in September 2009. The Veteran gave a history of elevated blood pressures in 1984 when he was in the service, and reported that his high blood pressure was associated with episodes of restlessness, tiredness, lightheadedness and dizzy spells. The examiner noted that the Veteran was started on medical treatment with anti-hypertensive medications in 1998. The examiner summarized pertinent STRs noting that the January 1983 enlistment examination showed blood pressure of 122/86; a subsequent entry of May 1985 showed blood pressure of 126/90; and a later entries of March 1987 and September 1987 revealed a blood pressure readings of 124/90 and 120/102. In October 1987, a blood pressure reading of 132/100 was made, and in June 1989 the Veteran's blood pressure was 150/102. It was noted that the separation physical examination of February 1988 showed a blood pressure of 130/92. Hypertension with left ventricular hypertrophy, on medical treatment, was diagnosed. The examiner opined that the evidence showed that the hypertension began during the Veteran's active duty service career with the initial blood pressure reading showing a slight elevation of his diastolic blood pressure (122/86) in January 1983. It was noted that a subsequent blood pressure reading showed a slight elevation of his diastolic blood pressure (126/90) in May 1985. It was observed that the highest recorded blood pressures were noted in October 1987 (132/100) and June 1989 (150/102). The examiner explained that based on these documented blood pressure readings in active duty service, he would opine that it is at least as likely as not that the hypertension began in service. Another examination was conducted in August 2012. The examiner observed that on induction examination of January 1983, blood pressure was 122/86, described as normal. It was also mentioned that the February 1988 separation examination showed blood pressure of 130/92. The examiner noted that the Veteran was seen on an emergent basis for back pain in May 1985, at which time blood pressure was 126/90. The examiner explained that hypertension is defined as blood pressure persistently greater than or equal to 140/90 on several visits over several months. It was concluded that no records dated from December 1983 to December 1986 showed a diagnosis of hypertension, and that at the earliest, this diagnosis was established in 1998. The examiner opined that the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in service injury, event, or illness. In April 2013 a QTC independent medical opinion was offered for the record addressing whether it was at least as likely as not that the Veteran's hypertension was incurred in or caused by service. The claims file and pertinent records were reviewed. The examiner opined that hypertension was at least as likely as not (50 percent or greater probability) incurred in or caused by service. It was explained that based upon review of pertinent medical records there were isolated elevated blood pressure readings documented in January 1983 as 122/86; 126/90 in 1985; and 126/90 in 1988. It was noted that prehypertension would likely turn into high blood pressure, defined as systolic pressure from 120 to 139 mm Hg or a diastolic pressure from 80 to 89 mm Hg. The examiner also observed that certain medications, including over the counter pain relievers and some prescription drugs, may also cause blood pressure to temporarily rise and noted that the Veteran was on pain medication when he suffered from back pain in 1985. It was further explained that hypertension develops gradually over many years without a specific identifiable cause. The Veteran presented testimony at a Board hearing held in September 2014. He stated that he didn't realize he had high blood pressure until 1988 when he started getting dizzy spells. He stated that he then looked at his STRs and saw recorded high blood pressure readings, but noted that he was never treated for hypertension in service. He stated that two QTC examiners had found that hypertension had its onset in service (p. 14). The Veteran maintains that service connection is warranted for hypertension, based on indications of elevated blood pressure readings in service. The medical criteria relevant to rendering a diagnosis of hypertension for VA purposes is governed by VA Training Letter 00-07 (July 17, 2000), which states that hypertension is present if the diastolic blood pressure is 90 mm Hg or more or the systolic pressure is 140 mm Hg or more, or if both are present. In isolated systolic hypertension, the systolic pressure is 140 mm Hg or more, but the diastolic pressure is less than 90 mm Hg. Indisputably, the record contains medical evidence of currently diagnosed hypertension, based on an initial diagnosis of this condition made in 1998. The Board notes that presumptive service connection is not applicable in this case because the evidence does not establish compensable hypertension within one year from the December 5, 1986 date of termination of honorable service. Thus, presumptive service connection is not warranted. 38 C.F.R. §§ 3.4, 3.12, 3.307, 3.309. The Board additionally finds that direct service connection is not warranted. Hypertension was never diagnosed during service or until nearly a decade later. Blood pressure readings made during the Veteran's honorable period of service, met VA's definition of hypertension on a sole occasion in May 1985, at which time blood pressure of 126/90 was recorded. Elevated blood pressure readings of 124/90 (March 1987); 126/94 (May 1987) and 130/92 (February 1988) were made during a period of dishonorable service. As such, these findings may not be considered in this case as pertains to the establishment of service connection. The Veteran is correct in observing that on two occasions (2009 and 2013) QTC examiners opined that hypertension was at least as likely as not (50 percent or greater probability) incurred in or caused by service. However, it is clear that at both times, the examiners incorrectly relied on blood pressure readings made during the period of dishonorable service in supporting the opinion, rendering those opinions inaccurate and unreliable. In this regard, medical opinions based on an inaccurate (or in this case an inapplicable) factual premise have limited, if any, probative value. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993); Swann v. Brown, 5 Vet. App. 229, 233 (1993). In contrast, the 2012 QTC opinion specifically only evaluated the blood pressure readings made during the Veteran's limited period of honorable service, concluding that hypertension was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in service injury, event, or illness. As this is the only medical opinion on file which was based on an accurate factual basis, the Board finds it to be the most probative evidence of record. Moreover, after carefully reviewing this evidence, the Board finds no adequate basis to reject this competent medical opinion which is unfavorable to the Veteran, based on a rational lack of credibility. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997); Evans v. West, 12 Vet. App. 22, 26 (1998). To the extent that the Veteran himself asserts he suffers from a hypertension as a result of service, or which had its onset was in service, the Board does not question the Veteran's sincerity of his beliefs. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, the etiology of hypertension, this falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). "Competent medical evidence" is evidence that is provided by a person qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. 38 C.F.R. § 3.159(a). Essentially it is beyond the Veteran's competency to link hypertension initially diagnosed years after service, to service or any incident therein, to include an isolated elevated blood pressure reading. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (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). Accordingly, the Board finds that the preponderance of the evidence is against the Veteran's service connection claim for hypertension. service connection claim for a heart condition with aortic valve repair must be denied. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claim of entitlement to service connection. As such, that doctrine is not applicable in the instant appeal, and his claim must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. See also Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). C. Service Connection for a Heart Condition The STRs include a January 1983 enlistment examination report revealing that clinical evaluation of the lungs, chest and heart was normal. On separation examination of February 1988, the STRs were entirely negative for complaints, treatment or a diagnosis relating to a heart disorder. Private medical records from the Beth Israel Medical Center reflect that the Veteran underwent repair of an ascending aortic dissection and aortic valve repair in early August 2000. A 1-year history of prior valvular heart disease was noted. On postoperative day five the Veteran developed progressive shortness of breath and an echocardiogram revealed a large pericardial effusion, which was also treated. In December 2005, the Veteran was treated at Long Island College Hospital for symptoms of chest pain, hearing loss, and left leg pain and weakness, ultimately assessed as a stroke. The file contains a March 2007 private medical statement of Dr. G.B. indicating that the Veteran had a history of a dissection aneurysm of the aorta with residual left hemiparesis. Records from the Social Security Administration reflect that disability benefits were approved from November 2006 based on a primary disability of aneurysm of the aorta with a secondary condition of diseases of the aortic valve. In an October 2008 statement, the Veteran alleged that chemical and tear gas exposure caused his claimed heart problems, and photographs were submitted purportedly showing such exposure. A QTC examination was conducted in September 2009. The Veteran gave a history of a defective aortic valve with an aortic aneurysm which initially was noted in 1998 and reported having open heart surgery in August of 2000. He also gave a history of cerebrovascular accident (stroke) in December of 2005 which resulted in some poststroke residuals including weakness in his left leg, impaired hearing, and renal insufficiency. It was also noted that in July of 2007, chronic type B aortic dissection and aortic insufficiency was treated and diagnosed. The Veteran complained of symptoms of intermittent chest pain, shortness of breath, lightheadedness, dizzy spells and fatigue. On examination, heart sounds were regular but there was a grade II systolic murmur noted over the left sternal border. There were no signs of congestive heart failure or cor pulmonale. Type B aortic aneurysm and status post aortic valve repair and repair of an aortic aneurysm (2000) were diagnosed. The examiner opined that it was at least as likely as not that the current heart condition is secondary to hypertension and was perhaps also aggravated by the Veteran's disclosure that he was diagnosed with sexually transmitted infections including gonorrhea and syphilis when he was on his first tour of duty between 1983 and 1986. Another examination was conducted in August 2012. Valvular heart disease, heart valve replacement diagnosed in 2000, and aortic aneurysm diagnosed in 2005, were recorded. The Veteran presented testimony at a Board hearing held in September 2014. He stated that his heart condition had its onset in 1999 and that a doctor had told him that his heart problems were linked to severe and chronic high blood pressure (p. 18). The Veteran maintains that service connection is warranted for a heart condition with aortic valve repair. His primary contention is that this condition is secondary to hypertension. In the alternative, he maintains that alleged in-service chemical and tear gas exposure caused his claimed heart problems (October 2008 statement). The Veteran has not contended and the evidence does not establish, or even suggest, that a heart condition had its onset during service or within the first post-service year. Where neither the Veteran nor the record raises the theory of entitlement to service connection on a direct basis, the Board need not sua sponte consider and discuss that theory. Therefore, the theory of direct service connection will be only briefly addressed herein and in conjunction with the aforementioned contentions, for the sake of completeness. Robinson v. Mansfield, 21 Vet. App. 545 (2008). With respect to evidence of current disability, post service private medical records document a diagnosis of valvular heart disease in 1999, with aortic valve repair in 2000. The Board notes that presumptive service connection is not applicable in this case because the evidence does not establish compensable cardiovascular disease within one year from the December 5, 1986 date of termination of honorable service. Thus, presumptive service connection is not warranted. 38 C.F.R. §§ 3.4, 3.12, 3.307, 3.309. With respect to the matter of service incurrence, the Veteran's STRs are negative for evidence of a diagnosed heart condition. The Veteran has provided vague and unsubstantiated accounts of chemical and tear gas exposure in service. These accounts, which were initially presented for the record almost 20 years after the Veteran's discharge from service, are not corroborated by the STRs or any post-service evidence; and photos of a different Veteran purportedly showing such exposure do not factually substantiate such accounts. Moreover, even if factually accurate, there has been no competent evidence presented for the record etiologically linking any such event and the development of heart disease a decade later. The Board need not find a lay Veteran competent to render opinions regarding the etiology of a diagnosed condition nor need the Board give any probative weight to bald assertions by a lay Veteran regarding that subject. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); King v. Shinseki, 700 F.3d 1339, 1344-45 (Fed. Cir. 2012). This Veteran, who lacks medical training, is not competent himself to opine on the etiology of his currently claimed heart condition. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Given the above findings, any assertion of an etiological link between alleged in-service chemical and tear gas exposure and the later development of heart disease is entirely meritless. For the foregoing reasons, the matter of service connection claim for a heart condition with aortic valve repair, on a direct or presumptive basis, must be denied. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against an award of service connection on a direct or presumptive basis, that doctrine is not applicable . See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Ortiz and Gilbert, supra. As for a secondary theory of entitlement, as indicated previously, the Veteran has primarily claimed that he currently has a heart condition with aortic valve repair as a result of hypertension. Service connection may be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a) (2014). That regulation permits service connection not only for disability caused by service-connected disability, but for the degree of disability resulting from aggravation of a nonservice-connected disability by a service-connected disability. Id; See also Allen v. Brown , 7 Vet. App. 439, 448 (1995). Significantly, however, as discussed above, the Veteran is not entitled to service connection for hypertension, As such, the Board finds that under the law, the Veteran lacks legal grounds to establish entitlement to service connection for a heart condition with aortic valve repair as secondary to hypertension. See Sabonis v. Brown, 6 Vet. App. 426 (1994). In Sabonis, the Court held that in cases in which the law and not the evidence is dispositive, a claim for entitlement to VA benefits should be denied or the appeal to the Board terminated because of the absence of legal merit or the lack of entitlement under the law. Insofar as service connection is not in effect for the disability claimed by the Veteran to have proximally caused or aggravated his heart condition, service connection on a secondary basis is not applicable under the law. As there is no legal entitlement, the claim of entitlement to service connection for a heart condition with aortic valve repair is without legal merit. Id. ORDER The appeal relating to the service connection claim for right ear hearing loss is dismissed. The appeal relating to the service connection claim for a right shoulder condition is dismissed. The appeal relating to the service connection claim for a right elbow condition is dismissed. The appeal relating to the service connection claim for a prostate condition is dismissed. The appeal relating to the service connection claim for residuals of a stab wound to the chest is dismissed. Service connection for hypertension is denied. Service connection for a heart condition with aortic valve repair is denied. REMAND The Board's review of the claims file reveals that additional AOJ action on the claims remaining on appeal is warranted. With respect to the increased initial rating claims for disabilities of the lumbar spine and left ankle, a review of the file reflects that examinations of the spine and ankle were most recently conducted in September 2009. During testimony provided at a Board hearing in September 2014, the Veteran essentially stated that he felt that his lumbar spine and left ankle disabilities had gotten worse since the 2009 examination. The Board observes that the duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate VA examination was conducted. See VAOPGCPREC 11-95. However, a new examination is appropriate when there is an assertion of an increase in severity since the last examination, as is essentially the case here. See 38 C.F.R. § 3.159 (2014); see also Palczewski v. Nicholson, 21 Vet. App. 174, 181 (2007); Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); VAOPGCPREC 11-95 (1995). Therefore, a new and contemporaneous examination should be administered to determine the manifestations and level of severity associated with the disabilities of the lumbar spine and left ankle. The Board observes that the Court has clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). Instead, in the Mitchell case it was explained that pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance (38 C.F.R. §§ 4.40), as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing (38 C.F.R. § 4.45). Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. Therefore, in requesting an examination for purposes for rating the severity of the low back and left ankle disabilities, the examiner will be asked to determine the overall level of functional impairment due to these factors. In his claim for compensation under 38 U.S.C.A. § 1151, the Veteran has asserted that he sustained a COPD exacerbation as a result of a nuclear stress test conducted at the Durham VAMC on September 1, 2009. The nuclear stress test was conducted due to the Veteran's frequent complaints of chest pain, and history of heart problems. During testing, the Veteran was unable to walk on the treadmill so the examiner administered adenosine, starting at 60 micrograms per kilogram per minute. The Veteran maintains that he sustained chronic side effects such as aggravated COPD and shortness of breath due to too great of a dose of adenosine. The file contains a May 2010 memorandum from the VA chief, cardiology to the risk management department of the Durham, NC VAMC. The reviewing cardiologist acknowledged that the Veteran exhibited intolerance to the adenosine during his stress test for atypical chest pain and noted that there was no evidence of wheezing and that cutaneous oxygen saturation remained normal. The doctor explained that adenosine is a ubiquitous chemical in the body, influencing blood flow in many tissues and is metabolized in plasma by deaminase which is present in the red blood cells. It was noted that Adenosine is gone in less than one minute after administration is discontinued and was selected as a means of chemical stress because of its extremely short duration of action. The doctor opined that there is virtually no possibility that the administration of this agent was a persistent cause of a disability. Emergency department notes from September 2009 through May 2010 from Craven Regional Medical Center and Carolinaeast Health System revealed a diagnosis of an exacerbation of COPD and reflect that this was explained as a possible side effect of adenosine. Also on file are articles from the American Society of Nuclear Cardiology, the University of Pittsburgh Medical Center, and the Cardiovascular Medical Group relating to stress testing and the use of adenosine. The Board finds that a medical opinion is warranted in connection with this claim. Indeed, VA has not afforded the Veteran a VA examination in conjunction with this appeal. As a result, there is no medical opinion of record that addresses whether the Veteran currently has chronic residuals of the September 2009 VA treatment as claimed, and if so, (1) whether it is at least as likely as not that the claimed residuals/ complications are a result of the VA's administration of adenosine during the September 2009 stress test and, (2) whether the proximate cause of such disability was (a) carelessness, negligence, or lack of proper skill, error in judgment, or similar instance of fault on the part of VA, or (b) an event not reasonably foreseeable. The medical examination and opinion requested herein will assist the Board in rendering a fully informed decision on the Veteran's claim for compensation under 38 U.S.C.A. § 1151. See 38 U.S.C.A. § 5103A (West 2014); 38 C.F.R. § 3.159 (2014); McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). The Veteran is hereby advised that failure to report for any scheduled examination(s), without good cause, may well result in denial of one or more claims. See 38 C.F.R. § 3.655(a)(b) (2014). Examples of good cause include, but are not limited to, the illness or hospitalization of the claimant and death of an immediate family member. Prior to arranging for the above-noted examinations, to ensure that all due process requirements are met, and the record is complete, the AOJ should undertake appropriate action to obtain and associate with the claims file all outstanding, pertinent records. As for VA records, the Board observes that it appears that the Veteran receives regular treatment through VA. A review of electronic claims files reflects that the Veteran's VA/CAPRI records current to December 2, 2013, were considered in conjunction with the most recent adjudication of the claims occurring in December 2013. Hence, it appears that more recent VA records may exist. The Board emphasizes that records generated by VA facilities that may have an impact on the adjudication of a claim are considered constructively in the possession of VA adjudicators during the consideration of a claim, regardless of whether those records are physically on file. See Dunn v. West, 11 Vet. App. 462,466-67 (1998); Bell v. Derwinski, 2 Vet. App. 611, 613 (1992). Accordingly, the AOJ should obtain all outstanding, pertinent VA records of evaluation hospitalization, and/or treatment of the Veteran from December 2013, forward, following the current procedures prescribed in 38 C.F.R. § 3.159(c) as regards requests for records from Federal facilities. The AOJ should also give the Veteran another opportunity to provide additional information and/or evidence pertinent to the claims remaining on appeal. The AOJ's letter to the Veteran should explain that he has a full one-year period for response. See 38 U.S.C.A. § 5103(b)(1) (West 214; but see also 38 U.S.C.A. § 5103(b)(3) (clarifying that VA may make a decision on a claim before the expiration of the one-year notice period). In its letter, the AOJ should specifically request that the Veteran furnish, or furnish appropriate authorization to obtain, any pertinent, outstanding private records. Thereafter, the AOJ should attempt to obtain any additional evidence for which the Veteran provides sufficient information and, if needed, authorization, following the current procedures prescribed in 38 C.F.R. § 3.159 (2014). The actions identified herein are consistent with the duties imposed by the Veterans Claims Assistance Act of 2000 (VCAA). See 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. § 3.159 (2014). However, identification of specific actions requested on remand does not relieve the AOJ of the responsibility to ensure full compliance with the VCAA and its implementing regulations. Hence, in addition to the actions requested above, the AOJ should also undertake any other development and/or notification action deemed warranted by the VCAA prior to adjudicating the claims remaining on appeal. The AOJs adjudication of each claim should include consideration of all evidence added to the record since the last adjudication of the claims in December 2013. Accordingly, these matters are hereby REMANDED for the following action: 1. Obtain all outstanding, pertinent VA records of evaluation, hospitalization, and/or treatment of the Veteran from December 2013, forward. Follow the current procedures prescribed in 38 C.F.R. § 3.159(c) as regards requests for records from Federal facilities. 2. Furnish to the Veteran and his representative a letter requesting that the Veteran provide information and, if necessary, authorization, to obtain any additional evidence pertinent to the pending initial increased rating claims for disabilities of the lumbar spine and left ankle; as well as for the claim of entitlement to compensation benefits pursuant to the provisions of 38 U.S.C.A. §1151, for a COPD exacerbation, claimed to have resulted from treatment at a VAMC on September 1, 2009, that are not currently of record. Specifically request that the Veteran provide, or provide appropriate authorization to obtain, any outstanding private medical records. Clearly explain to the Veteran that he has a full one-year period to respond (although VA may decide the claim within the one-year period). 3. If the Veteran responds, obtain all identified outstanding pertinent records of evaluation and/or treatment not currently of record-to include following the procedures set forth in 38 C.F.R. § 3.159 (2014). All records and responses received should be associated with the claims file. If any records sought are not obtained, notify the Veteran and his representative of the records that were not obtained, explain the efforts taken to obtain them, and describe further action to be taken. 4. After obtaining all outstanding treatment records, the Veteran should be scheduled for an appropriate VA examination to obtain information as to identity and severity of all manifestations associated with his service-connected disability of the left ankle. The contents of the entire, electronic claims file, to include a complete copy of this REMAND, must be made available to the designated individual, and the opinion/examination report should include discussion of the Veteran's documented medical history and assertions. All necessary diagnostic testing and evaluation should be completed. The Veteran's lay history of symptoms associated with the disabilities should be recorded. The examiner is asked to address the following matters and offer complete rationales for any opinions expressed: (a) Identify, by diagnosis, any currently manifested disorders of the left ankle, describing the symptomatology and impairment associated with the diagnosed disorders to the extent possible. If no such disorder is shown on examination, warranting no diagnosis, the examiner should specifically make such determination for the record and explain why it is concluded that no disability is shown. (b) Conduct range of motion studies of the left ankle (expressed in degrees), noting the exact measurements for flexion and extension, and specifically identifying any excursion of motion accompanied by pain. If pain on motion is observed, the examiner should comment on the extent of pain, and indicate at which point pain begins. (c) Determine whether the left ankle exhibits weakened movement, excess fatigability, or incoordination and, if feasible, these determinations should be expressed in terms of the degree of additional range of motion loss due to any weakened movement, excess fatigability, or incoordination. The examiner is also requested to discuss the overall level of functional impairment attributable to these factors. The examiner should express an opinion addressing whether pain could significantly limit functional ability during flare-ups or when the left ankle is used repeatedly over a period of time. This determination should also, if feasible, be portrayed in terms of the degree of additional range of motion loss due to pain on use or during flare-ups (d) The examiner should also provide an assessment as to whether the Veteran's overall range of motion of the left ankle is best characterized as moderately or markedly limited, as well as provide comment as to whether there is any ankylosis of the right ankle, malunion of the os calcis or astagalus, or astragalectomy. (e) The examiner is also asked to comment on the impact of the Veteran's disability of the left ankle, if any, on his employment and activities of daily life. All examination findings, along with complete, clearly-stated rationale for the conclusions reached, must be provided. 5. After obtaining all outstanding treatment records, the Veteran should be scheduled for an appropriate VA examination to obtain information as to identity and severity of all manifestations (orthopedic and neurologic) associated with his service-connected disability of the lumbar spine. The contents of the entire, electronic claims file, to include a complete copy of this REMAND, must be made available to the designated individual, and the opinion/examination report should include discussion of the Veteran's documented medical history and assertions. All necessary diagnostic testing and evaluation should be completed. The Veteran's lay history of symptoms associated with the disabilities should be recorded. The examiner is asked to address the following matters and offer complete rationales for any opinions expressed: (a) Identify, by diagnosis, any currently manifested disorders of the lumbar spine, describing the symptomatology and impairment associated with the diagnosed disorders to the extent possible. If no such disorders are shown on examination, warranting no diagnosis, the examiner should specifically make such determination for the record and explain why it is concluded that no disability is shown. (b) Provide the range of motion of the lumbar spine (extension, forward flexion, left and right lateral flexion and left and right rotation), expressed in degrees. (c) Determine whether the lumbar spine exhibits weakened movement, excess fatigability, or incoordination attributable to the service connected back disability and, if feasible, these determinations should be expressed in terms of the degree of additional range of motion loss due to any weakened movement, excess fatigability, or incoordination. The examiner is also requested to discuss the overall level of functional impairment attributable to these factors. The examiner should express an opinion addressing whether pain could significantly limit functional ability during flare-ups or when the lumbar spine is used repeatedly over a period of time. This determination should also, if feasible, be portrayed in terms of the degree of additional range of motion loss due to pain on use or during flare-ups. (d) Identify any neurological manifestations associated with the service-connected disability of the lumbar spine, as well as any associated bladder or bowel impairment. The nature of any neurological sign/symptom should be explained and the severity of the impairment described (in terms of the level of paralysis - mild/moderate/severe and incomplete or complete). (e) State whether the Veteran has intervertebral disc syndrome. If so, state whether intervertebral disc syndrome has been productive of incapacitating episodes, and if so, the number and duration of such episodes during any 12 month period extending from 2006 forward, specifying the time period involved. The examiner should note that for VA purposes an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. (f) The examiner is also asked to comment on the impact of the Veteran's disability of the lumbar spine, if any, on his employment and activities of daily life. All examination findings, along with complete, clearly-stated rationale for the conclusions reached, must be provided. 6. After all records and/or responses received from each contacted entity have been associated with the claims file, arrange for an examination to be conducted by an appropriate physician to include providing opinions and addressing the matters below. The contents of the entire, electronic claims file, to include a complete copy of this REMAND, must be made available to the designated individual, and the opinion/examination report should include discussion of the Veteran's documented medical history and assertions. (a) Identify, by diagnosis and associated symptoms, any additional disability which has manifested since the VA stress test took place on September 1, 2009, primarily claimed as exacerbated COPD and shortness of breath. If no such disability is shown on examination, warranting no diagnosis, the examiner should specifically make such determination for the record and explain why it is concluded that no disability is shown. (b) Then, the physician should render an opinion, consistent with the record and sound medical judgment, as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that any currently claimed/manifested additional disability was incurred as a result care received at the Durham, NC VAMC on September 1, 2009, to include inadequate or inappropriate treatment. (c) If so, the physician should also opine as to whether the proximate cause of such additional disability was (a) carelessness, negligence, or lack of proper skill, error in judgment, or similar instance of fault on the part of VA, or (b) an event not reasonably foreseeable. In addressing the above, the physician should consider and discuss the Veteran's development and progression of COPD and other respiratory symptoms and associated complications. The physician should comment as to whether, in providing the Veteran's care on September 1, 2009 at the Durham, NC VAMC, any VA health professional failed to exercise the degree of care that would be expected of a reasonable health care provider. All pertinent lay and medical evidence (to include a May 2010 memorandum from the risk management department of the Durham, NC VAMC; emergency department notes from September 2009 through May 2010 from Craven Regional Medical Center and Carolinaeast Health System; and articles to include those from the American Society of Nuclear Cardiology, the University of Pittsburgh Medical Center, and the Cardiovascular Medical Group) should be addressed. All examination findings along with complete, clearly-stated rationale for the conclusions reached, must be provided. 7. To help avoid future remand, ensure that all requested actions have been accomplished (to the extent possible) in compliance with this REMAND. If any action is not undertaken, or is taken in a deficient manner, appropriate corrective action should be undertaken. Stegall v. West, 11 Vet. App. 268 (1998). 8. After completing the requested action, and any additional notification and/or development deemed warranted, adjudicate the matters remaining on appeal in light of all pertinent evidence and legal authority. 9. If any benefit sought on appeal remains denied, furnish to the Veteran and his representative an appropriate SSOC that includes citation to and discussion of all additional legal authority considered, as well as clear reasons and bases for all determinations, and afford them an appropriate time period for response before the claims file is returned to the Board for further appellate consideration. The purpose of this REMAND is to afford due process and to accomplish additional development and adjudication; it is not the Board's intent to imply whether the benefits requested should be granted or denied. The Veteran need take no action until otherwise notified, but he may furnish additional evidence and/or argument during the appropriate time frame. See Kutscherousky v. West, 12 Vet. App. 369 (1999). This REMAND must be afforded expeditious treatment. The law requires that all claims 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 2014). ______________________________________________ JACQUELINE E. MONROE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs