Citation Nr: 0810919 Decision Date: 04/02/08 Archive Date: 04/14/08 DOCKET NO. 02-01 857 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Manila, the Republic of the Philippines THE ISSUES 1. Whether new and material evidence has been received sufficient to reopen a claim of entitlement to service connection for a low back disability, to include degenerative changes of the lumbar spine and disc herniation at the L4-5 interspace. 2. Entitlement to service connection for hypertension (HTN). 3. Entitlement to service connection for lateral epicondylitis of the left elbow. 4. Entitlement to service connection for right rotator cuff tendonitis. 5. Entitlement to service connection for left rotator cuff tendonitis. 6. Entitlement to service connection for hematuria. 7. Entitlement to service connection for chronic bronchitis. 8. Entitlement to service connection for a gastrointestinal disorder, claimed as gastroenteritis. WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD K.A. Kennerly, Associate Counsel INTRODUCTION The veteran served on active duty from March 1968 to June 1990. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2000 rating decision of the Manila, the Republic of the Philippines, Regional Office (RO) of the Department of Veterans Affairs (VA), which denied the veteran's claims. With regard to the veteran's claim of entitlement to service connection for a low back disability, to establish jurisdiction over this issue, the Board must first consider whether new and material evidence has been submitted to reopen the claim. See 38 U.S.C.A. §§ 5108, 7104 (West 2002 & Supp. 2007). The Board must proceed in this fashion regardless of the RO's actions. See Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996) and VAOPGCPREC 05-92. As discussed fully below, new and material evidence has been submitted to reopen the claim. The veteran participated in a decision review officer hearing in January 2002. A transcript of that proceeding has been associated with the veteran's claims file. The Board previously remanded these claims in October 2003 and May 2006 for additional development. The veteran submitted additional evidence to the Board in January 2008. Though the veteran did not provide the appropriate waiver of agency of original jurisdiction consideration, the Board may proceed without prejudice to the veteran. The evidence submitted included duplicate copies of medical records already associated with the claims file, diagnoses already of record and new evidence pertaining to his low back condition. As the Board has herein granted the veteran's claim for service connection for a low back disability, he has not been prejudiced. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements in the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran are to be avoided). FINDINGS OF FACT 1. A rating decision in January 1991 denied the veteran's claim of entitlement to service connection for a low back condition. 2. Evidence submitted subsequent to the January 1991 RO decision bears directly and substantially upon the specific matter under consideration, is not cumulative or redundant, and in connection with evidence previously assembled is so significant that it must be considered in order to fairly decide the merits of the claim for service connection. 3. The veteran's current low back disability, degenerative changes of the lumbar spine and disc herniation at the L4-5 interspace, is the result of a disease or injury in active duty service. 4. Hypertension is not shown by competent medical evidence to be linked to a disease or injury in service and it was not manifested within the first post-service year. 5. Lateral epicondylitis of the left elbow is not shown by the competent medical evidence to be linked to a disease or injury in service. 6. Bilateral rotator cuff tendonitis is not shown by the competent medical evidence to be linked to a disease or injury in service. 7. Hematuria is not shown by the competent medical evidence to be linked to a disease or injury in service. 8. Chronic bronchitis is not shown by the competent medical evidence to be linked to a disease or injury in service. 9. A gastrointestinal disorder, claimed as gastroenteritis, is not shown by the competent medical evidence to be linked to a disease or injury in service. CONCLUSIONS OF LAW 1. The January 1991 RO decision denying entitlement to service connection for a low back condition is final. 38 U.S.C.A. §§ 7103(a) and 7105 (West 2002 & Supp. 2007). 2. Evidence received subsequent to the January 1991 RO decision is new and material and the veteran's claim of entitlement to service connection for a low back condition is reopened. 38 U.S.C.A. §§ 5108, 7105 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.156 (as in effect prior to August 29, 2001); 38 C.F.R. §§ 3.104(a), 20.1103 (2007). 3. A low back disability, to include degenerative changes of the lumbar spine and disc herniation at the L4-5 interspace, is the result of active military service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.303, 3.304 (2007). 4. Hypertension was not incurred in or aggravated by active military service and may not be presumed to be related thereto. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1133, 1137, 5107 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2007). 5. Lateral epicondylitis of the left elbow was not incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.303, 3.304 (2007). 6. Bilateral rotator cuff tendonitis was not incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.303, 3.304 (2007). 7. Hematuria was not incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.303, 3.304 (2007). 8. Chronic bronchitis was not incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.303, 3.304 (2007). 9. A gastrointestinal disorder, claimed as gastroenteritis, was not incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.303, 3.304 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claims. The veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the veteran). The Board must assess the credibility and weight of all 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. 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 all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). I. The Veterans Claims Assistance Act of 2000 (VCAA) With respect to the veteran's claims decided herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2007). The Board is granting in full the claim of entitlement to service connection for a low back disability. Accordingly, assuming, without deciding, that any error was committed with respect to either the duty to notify or the duty to assist in this particular claim, such error was harmless and will not be further discussed. Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2007); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II), the United States Court of Appeals for Veterans Claims (Court) held that VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claims; (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) request that the claimant provide any evidence in his possession that pertains to the claim. With regard to the veteran's remaining claims, letters dated in March 2001, March 2004 and May 2006 fully satisfied the duty to notify provisions. See 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b)(1) (2007); Quartuccio, at 187. The veteran was aware that it was ultimately his responsibility to give VA any evidence pertaining to the claims. The aforementioned letters told him to provide any relevant evidence in his possession. See Pelegrini II, at 120-21. Although the March 2001 letter was not sent prior to initial adjudication of the veteran's claims, this was not prejudicial to him, since (1) he filed his claims prior to the enactment of the VCAA, (2) he was subsequently provided adequate notice in March 2001, March 2004 and May 2006 and (3) the claims were readjudicated and an additional supplemental statement of the case was provided to the veteran in October 2007. See Prickett v. Nicholson, 20 Vet. App. 370 (2006). The Board also notes that the veteran was provided notice of how VA determines disability ratings and effective dates in May 2006, compliant with Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Board notes that the RO did not identify the veteran's claim of entitlement to service connection for a low back disability as a petition to reopen a previously denied claim. As noted above, the Board must do so in order to retain jurisdiction of this issue. Not only was the veteran not provided with notice of what he needed to submit in order to reopen his claim, during the pendency of this appeal, the Court issued a decision in the appeal of Kent v. Nicholson, 20 Vet. App. 1 (2006), which established significant new requirements with respect to the content of the notice necessary for those cases involving the reopening of previously denied claims. Specifically, the Court held that VA must notify a claimant of the evidence and information that is necessary to reopen the claim and VA must notify the claimant of the evidence and information that is necessary to establish his entitlement to the underlying claim for the benefit sought by the claimant. In the present case, the veteran's claim of entitlement to service connection for a low back disability need not be remanded for this oversight. While he did not receive this notice, the veteran is not prejudiced as the Board has reopened and granted his claim. The Board also concludes VA's duty to assist has been satisfied. The veteran's service medical records and VA medical records are in the file. Private medical records identified by the veteran have been obtained, to the extent possible. The veteran has at no time referenced outstanding records that he wanted VA to obtain or that he felt were relevant to the claims. The veteran was afforded VA medical examinations in August 1990, October 2006, February 2007, April 2007 and May 2007 to obtain opinions as to whether his disabilities could be directly attributed to service. Further examinations or opinions are not needed on the claims because, at a minimum, there is no persuasive and competent evidence that the claimed conditions may be associated with the veteran's military service. This is discussed in more detail below. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). II. New and Material Evidence Where service connection for a disability has been denied in a final decision, a subsequent claim for service connection for that disability may be considered on the merits only if new and material evidence has been received since the time of the prior adjudication. As noted above, the Board must consider the question of whether new and material evidence has been received because it goes to the Board's jurisdiction to reach the underlying claim and adjudicate the claim de novo. See Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001); Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996). If the Board finds that no such evidence has been offered, that is where the analysis must end, and what the RO may have determined in that regard is irrelevant. See Barnett, supra. Further analysis, beyond consideration of whether the evidence received is new and material, is neither required nor permitted. Id. at 1384. See also Butler v. Brown, 9 Vet. App. 167, 171 (1996). In September 1998, the United States Court of Appeals for the Federal Circuit (Federal Circuit) issued an opinion which overturned the test for materiality established by the Court in Colvin v. Derwinski, 1 Vet. App. 171, 174 (1991) (the so-called "change in outcome" test). See Hodge v. West, 155 F.3d 1356 (Fed. Cir. 1998). The Federal Circuit in Hodge mandated that materiality be determined solely in accordance with the definition provided in 38 C.F.R. § 3.156(a). (It is noted that 38 C.F.R. § 3.156(a) was amended in August 2001. However, that amendment is applicable only to claims filed on or after August 29, 2001. See 66 Fed. Reg. 45,620 (Aug. 29, 2001)). It does not apply to the veteran's claim as he filed his claim to reopen in December 1999. Under 38 C.F.R. § 3.156(a) (2001), evidence is considered "new" if it was not of record at the time of the last final disallowance of the claim and if it is not merely cumulative or redundant of other evidence that was then of record. See also Struck v. Brown, 9 Vet. App. 145, 151 (1996); Blackburn v. Brown, 8 Vet. App. 97, 102 (1995); Cox v. Brown, 5 Vet. App. 95, 98 (1993). "Material" evidence is evidence which bears directly and substantially upon the specific matter under consideration, and which by itself or in connection with evidence previously assembled is so significant that it must be considered in order to fairly decide the merits of the claim. See 38 C.F.R. § 3.156(a) (2001). In determining whether evidence is new and material, the "credibility of the evidence is to be presumed." See Justus v. Principi, 3 Vet. App. 510, 513 (1992). By decision dated in January 1991, the RO denied the veteran's claim of entitlement to service connection for a low back condition. Under applicable law and VA regulations, that decision is final, and the veteran's claim may not be reopened and reviewed unless new and material evidence is submitted by or on behalf of the veteran. See 38 U.S.C.A. § § 5108, 7105; 38 C.F.R. §§ 3.104 (a), 3.156 (2001). It is determined that since the January 1991 RO decision, the veteran has submitted new and material evidence in order to reopen his claim. New evidence consists of VA examination reports and numerous private treatment records. The January 1991 RO decision denied the veteran's claim for a low back condition because there was no evidence of a diagnosis in service and no competent evidence which linked the veteran's low back pathology to his active duty service. The newly submitted evidence is not cumulative or redundant. It has not been submitted before. Since the evidence relates to a crucial question in the veteran's case, i.e., whether he suffers from a low back condition as a result of a disease or injury in service, the newly received evidence is of such significance that it must be considered in order to fairly decide the merits of the claim, and it is determined to be material to the veteran's claim. Accordingly, the claim is reopened, and must be considered in light of all the evidence, both old and new. III. The Merits of the Claims Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by active service. See 38 U.S.C.A. § 1110 (West 2002). For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. See 38 C.F.R. § 3.303(b) (2007). If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. Id. Service connection may be granted for any disease diagnosed after discharge, when all of the evidence establishes that the disease was incurred in service. See 38 C.F.R. § 3.303(d) (2007). In order to establish service connection for the claimed disorder, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). A. Low Back Disability Having reopened the veteran's claim of entitlement to service connection for a low back disability, the Board now turns to whether the veteran's disability is service connected. Review of the claims file indicates the veteran currently suffers from degenerative changes of the lumbar spine, to include disc herniation at the L4-5 interspace. See Hickson, supra. Upon review of the veteran's service medical records, the Board finds that the veteran did not complain of or receive treatment for a low back disability during his time in service. When the veteran participated in his service discharge examination in March 1990, he noted that he suffered from low back pain at night. See Standard Form (SF) 93, separation examination report, March 3, 1990. The veteran filed his original claim of entitlement to service connection for a low back disability in July 1990. During the pendency of that claim, the veteran was afforded a VA examination in August 1990. The veteran reported continuous low back pain for the prior 10 years. The pain was noted to be at night, though there was no history of a specific injury. The veteran was diagnosed with muscular low back pain. The x-ray report associated with the VA examination found the veteran's spine to be normal. In July 1999, the veteran was seen at St. Dominic Medical Center for a computed tomography (CT) scan of the lumbar spine. The impression was degenerative changes of the lumbar spine and disc herniation at the L4-5 interspace. See St. Dominic Medical Center, CT scan report, July 6, 1999. The veteran had a second CT scan of the lumbar spine in September 2000. The results again indicated disc herniation at the L4-5 interspace but also noted facet joint hypertrophy. See De La Salle University Medical Center, CT scan report, September 28, 2000. In November 2003, the veteran had magnetic resonance imaging (MRI) of the lumbar spine. The impression was mild, diffuse disc bulge at L4-5 with bilateral neuroforaminal narrowing. See Asian Hospital, MRI report, November 26, 2003. In 2004, the veteran underwent multiple physical therapy sessions for his back pain. See San Juan De Dios Educational Foundation, Inc., physical therapy notes, 2004. The veteran was afforded a VA spine examination in October 2006. The veteran reported that he was used to carrying heavy aeronautical objects in his military occupational specialty (MOS) as an aviation storekeeper and noted low back pain that was initially tolerable. He experienced pain when stooping down, lying down for a long period of time, prolonged standing, sitting and walking. The veteran noted that his condition progressed as he later began to experience pain radiating into his right leg. Imaging studies revealed spondylolisthesis of L4-5. The examiner diagnosed the veteran with a herniated disc at L4-5 with radiculopathy and degenerative disc disease. See VA examination report, October 25, 2006. As the VA examiner did not provide an opinion as to the nature and etiology of the veteran's lumbar spine disabilities in October 2006, the RO requested an addendum to address this question. The examiner responded in May 2007. It was noted that low back pain could be a symptom of disc disease. The examiner concluded that the veteran's complaints of back pain at bedtime on the March 1990 discharge examination were at least as likely as not related to his present disabilities. A normal physical examination and x-ray performed at the veteran's discharge would not rule out the possibility of any disc conditions that may have been present. The examiner also noted that some disc conditions may not be evident on an x-ray during the early stages of the disease and there may be a discrepancy between the severity of the symptoms and the results of the x-rays. See VA examination report addendum, May 7, 2007. The Board finds the VA positive nexus opinion to be persuasive. The evidence in this case is approximately balanced regarding the question of whether the veteran's current low back disability is the result of a disease or injury in service. Therefore, the benefit-of-the-doubt will be conferred in his favor and his claim for service connection for a low back disability is granted. See 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2007); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). B. Hypertension, Left Elbow Disability and Bilateral Rotator Cuff Disabilities The veteran alleges that his HTN, left elbow disability and bilateral rotator cuff disabilities are the result of disease or injury in service. The preponderance of the evidence is against these claims, and the Board finds that the veteran's claims must fail. HTN means persistently high arterial blood pressure, and by some authorities the threshold for high blood pressure is a reading of 140/90. See Dorland's Illustrated Medical Dictionary at 889 (30th ed. 2003). For VA purposes, hypertension means that the diastolic pressure is predominantly 90 or greater, and isolated systolic hypertension means that the systolic pressure is predominantly 160 or greater with a diastolic pressure of less than 90. See 38 C.F.R. § 4.104, Diagnostic Code 7101 (2007). Where a veteran served continuously for 90 days or more during a period of war, or during peacetime service after December 31, 1946, and hypertension becomes manifest to a degree of 10 percent within 1 year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. See 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1137 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.307, 3.309 (2007). The first showing of hypertension in the record is the private treatment record dated in 1999. There is no evidence to support a finding that the veteran's hypertension was compensable to a 10 percent degree within the first post-service year. Therefore, service connection on a presumptive basis is not warranted. Initially, the Board notes that the veteran has been diagnosed with HTN, medial and lateral epicondylitis of the left elbow and bilateral rotator cuff tendonitis. See VA examination reports, October 23, 2006 and April 23, 2007; St. Dominic Medical Center, physician therapy note, November 20, 1999; and VA examination report, May 7, 2007. Thus, the Board concedes the veteran currently suffers from the claimed disabilities. See Hickson, supra. Review of the veteran's service medical records is completely negative for any treatment of HTN, a left elbow disability or bilateral rotator cuff disabilities. The veteran's blood pressure was measured on each of his service examinations and at no point did it exceed diastolic pressure of 90 and systolic pressure of 160. See service medical records; entrance, periodic and separation examinations; October 1967 through March 1990. On the veteran's service discharge examination, the veteran noted that he was unsure if he was hypertensive and complained of slight muscle pain of the left arm. The examiner noted there was no history of HTN (the veteran's blood pressure was noted as 100/72) and no diagnosis was made regarding the veteran's left arm pain complaint. See SF 93, separation examination report, March 3, 1990. The first medical treatment records diagnosing the veteran with HTN were dated in December 1999, where it was noted he had Stage I-III HTN. See St. Dominic Medical Center, private treatment record, December 13, 1999. A physical therapy note dated in November 1999 diagnosed the veteran with bilateral rotator cuff tendonitis and medial and lateral epicondylitis of the left elbow. The veteran reported that he began to experience left elbow pain in approximately November 1998. The veteran noted that his bilateral shoulder pain had been present since 1986. See St. Dominic Medical Center, physical therapy note, November 20, 1999. At the outset, the Board notes that the veteran was not diagnosed with HTN, a left elbow disability or bilateral rotator cuff disabilities until 1999, almost 10 years after his discharge from active duty service. The absence of evidence for the approximately 10-year period constitutes negative evidence tending to disprove the claims that the veteran had injuries in service which resulted in chronic disabilities or persistent symptoms thereafter. See Forshey v. West, 12 Vet. App. 71, 74 (1998), aff'd sub nom. Forshey v. Principi, 284 F.3d 1335, 1358 (Fed. Cir. 2002) (noting that the definition of evidence encompasses "negative evidence" which tends to disprove the existence of an alleged fact); see also 38 C.F.R. § 3.102 (noting that reasonable doubt exists because of an approximate balance of positive and "negative" evidence). The veteran was afforded VA examinations in October 2006. During the VA general examination, the examiner noted the veteran's HTN existed since the 1980's, was controlled by medication and was the result of a disease or injury in service. See VA general examination report, October 23, 2006. Though this does constitute a positive medical nexus, the Board notes that the examiner did not review the veteran's claims folder in conjunction with the examination. Whether a physician provides a basis for his or her medical opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician's access to the claims folder and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000). As the VA examiner did not review the veteran's claims file, the aforementioned opinion was based purely on history provided by the veteran. In Black v. Brown, 5 Vet. App. 177, 180 (1993), the Court stated that the Board may discount medical opinions that amount to general conclusions based on history furnished by the veteran and that are unsupported by the clinical evidence. Based on the review of the service medical records, it is clear that the veteran had not yet been diagnosed with HTN in the 1980's and in fact was first diagnosed in 1999. Accordingly, this VA opinion is not afforded any evidentiary weight. The examiner was later requested to review the veteran's claims file and provide an addendum to the October 2006 examination report. The examiner replied in April 2007, noting that the claims file had been reviewed. It was noted that HTN was not seen during review of the veteran's service medical records. A blood pressure reading dated in 1985 showed normal blood pressure at 120/76. See VA examination report addendum, April 23, 2007. As there was no evidence of HTN in service and no positive medical nexus, the veteran's claim of entitlement to service connection for HTN must fail. See Hickson, supra. The veteran also participated in a VA joints examination in October 2006. The veteran reported having bilateral shoulder and left elbow pain since the 1980's. The veteran reported undergoing physical therapy since 2000, which has afforded him temporary relief. He denied any history of trauma or surgery to these areas. The veteran was diagnosed with soft tissue rheumatism with moderate daily effects. See VA joints examination report, October 25, 2006. The corresponding x-rays of the veteran's left elbow and bilateral shoulders returned normal studies. See VA examination x-ray reports, October 25, 2006. As the VA examiner did not provide an opinion as the nature and etiology of the veteran's left elbow and bilateral shoulder disabilities, an addendum was requested. The May 2007 addendum stated that since there was no record of any complaints or treatment for these conditions in the veteran's service medical records, the examiner could not resolve this issue without resorting to mere speculation. See VA examination report addendum, May 7, 2007. Thus, there is no competent medical evidence of a nexus between any current disabilities and an event or incident of service. The only remaining evidence in support of the veteran's claims is lay statements alleging that the veteran currently suffers from a left elbow disability and bilateral shoulder disabilities that are the result of his active duty service. The Board acknowledges that the veteran is competent to give evidence about what he experiences; for example, he is competent to discuss his symptomatology. See, e.g., Layno v. Brown, 6 Vet. App. 465 (1994). He is not, however, competent to diagnose any medical disorder or render an opinion as to the cause or etiology of any current disorder because he does not have the requisite medical knowledge or training. See Rucker v. Brown, 10 Vet. App. 67, 74 (1997) (stating that competency must be distinguished from weight and credibility, which are factual determinations going to the probative value of the evidence). Accordingly, the Board concludes that the preponderance of the evidence is against these claims for service connection, and the benefit of the doubt rule enunciated in 38 U.S.C.A. § 5107(b) is not for application. In this case, for the reasons and bases discussed above, a reasonable doubt does not exist regarding the veteran's claims that his current bilateral shoulder and left elbow disabilities are related to service. There is not an approximate balance of evidence. C. Hematuria, Chronic Bronchitis and Gastroenteritis The veteran alleges that his claimed conditions of hematuria, chronic bronchitis and gastroenteritis are the result of disease or injury in service. The preponderance of the evidence is against a finding that these conditions are due to service. Review of the veteran's service medical records reveals that upon entry, the veteran did not complain of any of the aforementioned conditions. All his internal systems were considered normal and the veteran reported being in good health. See service medical records, entrance examination reports, SF 88 and 89, October 16, 1967. In March 1968, the veteran complained of blood in his urine. The examiner diagnosed him as asymptomatic with hematuria of unknown etiology. See service medical record, March 25, 1968. The veteran was seen again for follow up of his complaints in April 1968. The examiner again diagnosed the veteran as asymptomatic, but noted microhematuria. The examiner also noted the veteran had no history of renal disease, stones or bright red blood in his urine. See service medical record, April 1, 1968. The veteran had a blood test in May 1968, which revealed his creatinine and uric acid levels to be within normal limits. See service medical record, May 7, 1968. A periodic examination in March 1972 noted the veteran's evaluation for hematuria in 1968 with no sequelae. See service medical record, periodic examination report, SF 88, March 10, 1972. In April 1974, the veteran was again diagnosed with microscopic hematuria. See service medical record, periodic examination report, SF 88, April 29, 1974. There were no further complaints of hematuria during the veteran's time in service. In fact, on the veteran's separation examination, the examiner noted a history of hematuria in 1968 with no repeats. See service medical record, service discharge examination report, March 3, 1990. In March 1977, the veteran was seen with complaints of having a severe cold, and was diagnosed with acute bronchitis. See service medical record, March 1, 1977. The veteran was seen in September 1980 with complaints of diarrhea. The examiner diagnosed him with possible acute gastroenteritis. See service medical record, September 11, 1980. However, on the veteran's separation examination, all of the veteran's internal systems were considered normal and he had no complaints of gastrointestinal difficulties or bronchitis. See service medical record, service discharge examination report, March 3, 1990. As such, the Board concedes that the veteran did complain of and receive treatment for hematuria, chronic bronchitis and gastroenteritis during his time in service. The Board also concedes that the veteran has been diagnosed with current disabilities of hematuria, chronic bronchitis and gastroenteritis. See Hickson, supra. Now the Board turns to the question of medical nexus. Regarding hematuria, there is no evidence of treatment for this condition between 1968 and 2003. The veteran was admitted on December 11, 2003 due to persistent painless hematuria. See private treatment record, Benjamin Ramos, Jr., M.D., December 11, 2003. At that time, the veteran was also afforded an ultrasound of his abdomen. The results showed normal liver, gallbladder, pancreas, spleen and urinary bladder. Id. In April 2004, the veteran was seen by Dr. Ramos for an extracorporeal shockwave lithotripsy. Dr. Ramos diagnosed the veteran with hematuria, ureterolithiasis, left proximal third non-obstructing calyceal calculi, a left parapelvic cyst and a left renal cortical cyst. See private treatment record, Benjamin Ramos, Jr., M.D., April 13, 2004 and August 19, 2004. The veteran was seen again by Dr. Ramos in January 2005. During his January 2005 visit, the veteran was diagnosed with benign prostatic hypertrophy and hematuria of unknown etiology. Urinalysis showed microscopic hematuria and pyuria. The urine culture was negative. Upon examination, the veteran's kidneys were of normal size with parapelvic cystic masses. The veteran was discharged with no definitive etiology regarding his hematuria. See private treatment record, Benjamin Ramos, Jr., M.D., January 2, 2005. The veteran participated in a VA general examination in October 2006. The veteran reported having red blood cells in his urine during service. The examiner noted that the etiology of the hematuria was not known, even after work-up. The examiner noted the veteran had a history of stones in the urethra in 2004 and had cysts on both kidneys. Though the examiner did state that the veteran's hematuria was the result of his time in service, as noted above, the examiner did not review the veteran's claims file in conjunction with the examination and based the opinion on history provided by the veteran. See Hernandez-Toyens, supra; Prejean, supra. As such, it is not considered persuasive. The examiner was requested to provide an addendum to the original examination after reviewing the veteran's claims file. In April 2007, the examiner noted that the claims file had been reviewed. The examiner stated that medical evaluations in the past failed to determine the etiology of the veteran's hematuria, but for elevated calcium levels. Stones were not ruled out as the hematuria's etiology since the veteran had a lithotripsy in 2004 for his urinary tract stones. See VA examination report addendum, April 23, 2007. Regarding chronic bronchitis, the veteran was afforded a VA respiratory disorders examination in May 2007. The examiner noted that the veteran was seen in service one time with complaints of a cough with white/yellow sputum for two weeks, with a diagnosis of chronic bronchitis in March 1977. There were no other recurrences during the veteran's time in service. The examiner also noted a March 1975 consultation note where the veteran complained of a productive cough and was diagnosed with flu syndrome. The examiner also noted the March 1990 separation examination which demonstrated a normal examination of the lungs and chest. The examiner stated that the veteran is a previous smoker, who stopped in approximately 2003. The veteran complained of a dry intermittent cough in service, which he attributed to his smoking. Upon physical examination, the veteran had no signs of benign or malignant neoplasm. His heart sounds were normal, there were no signs of venous congestion, there were no respiratory abnormalities and chest expansion was normal. X-rays of the chest revealed a prominent aorta, but an otherwise normal chest. Pulmonary function tests (PFT) revealed a moderate obstructive ventilatory pattern with significant response to bronchodilators. The examiner diagnosed the veteran with chronic bronchitis and noted he was previously a smoker. The examiner concluded that based on the PFT, the etiology of the veteran's dry cough is chronic bronchitis. The veteran was a chronic smoker who stopped smoking only in 2003. Whether this was present in service, the examiner could not determine without resorting to speculation. The veteran sought medical consultation only once for a productive cough and fever in service, with a diagnosis of acute bronchitis. There was no recurrence of this condition and the veteran did not complain of intermittent productive cough, easy fatigue or other symptoms attributable to the respiratory tract, but he was a smoker while in service. See VA respiratory examination report, May 21, 2007. Regarding gastroenteritis, the veteran was seen in July 1999 for an abdominal ultrasound. The impression was that the liver, pancreas, spleen, urinary bladder, gallbladder and prostate gland were normal, though the veteran did demonstrate bilateral renal cysts. See St. Dominic Medical Center, abdominal ultrasound, July 15, 1999. In August 1999, the veteran had a CT scan of his abdomen. The impression was bilateral renal cysts. His liver, gallbladder, pancreas and spleen were considered normal. See private treatment record, St. Dominic Medical Center, CT scan of abdomen, August 10, 1999. At the beginning of September 1999, the veteran was admitted for complaints of abdominal pain. He was later diagnosed with acute gastritis. See private treatment note, Dagupan Doctors - Villaflor Memorial Hospital, September 4th and 5th, 1999. On September 7, 1999, the veteran was diagnosed with peptic ulcer disease. See private treatment record, Agape Medical Clinic, September 7, 1999. In December 2003, the veteran was again admitted with complaints of abdominal pain. His admitting diagnosis was peptic ulcer disease, and he was ultimately diagnosed with chronic gastritis. An abdominal ultrasound of the abdomen demonstrated kidney cysts, but was otherwise normal. An esophagogastroduodenoscopy was also performed and the veteran was again diagnosed with chronic gastritis. See private treatment records, Our Lady of Pillar Medical Center, December 2003. The veteran participated in the VA general examination in October 2006, but as noted above, the veteran's claims file was not reviewed in conjunction with the examination. Therefore, the conclusion that the veteran's gastritis is related to service is not persuasive. See Hernandez-Toyens, supra; Prejean, supra. The requested addendum in April 2007 noted that there was no evidence in the veteran's service medical records of continuous epigastric complaints or any complaints attributable to peptic acid disease or esophagitis. See VA examination report addendum, April 23, 2007. The veteran was later afforded a VA examination in May 2007 that noted although the veteran had findings of gastritis in the past, his fecal occult blood test was negative, which rules out chronic blood loss due to his gastrointestinal problems. His physical examination was normal. See VA examination report, May 21, 2007. As there is no evidence the veteran suffered from hematuria between 1968 and 2003; no evidence he suffered from chronic bronchitis between 1977 and 2007; and no evidence he suffered from gastroenteritis between 1980 and 1999, the Board finds that the absence of evidence for the approximately 20 to 30 year period constitutes negative evidence tending to disprove the claims that the veteran had injury or disease in service which resulted in chronic disabilities or persistent symptoms thereafter. See Forshey, supra. There is no other evidence of record that provides a positive and persuasive medical nexus opinion in support of the veteran's claims. As noted above, the Board empathizes with the veteran's claim that he believes his current conditions are due to injuries in service. The Board also acknowledges that the veteran stated he could not afford healthcare for a long period of time. Unfortunately, there is no medical evidence to substantiate his claims that his hematuria, chronic bronchitis and gastroenteritis are related to service. See Layno, supra. Since there is no positive medical nexus to connect his current disabilities to service, the veteran's claims must fail. ORDER The claim of entitlement to service connection for a low back disability, degenerative changes of the lumbar spine and disc herniation at the L4-5 interspace, is reopened and granted. Entitlement to service connection for hypertension (HTN) is denied. Entitlement to service connection for lateral epicondylitis of the left elbow is denied. Entitlement to service connection for right rotator cuff tendonitis is denied. Entitlement to service connection for left rotator cuff tendonitis is denied. Entitlement to service connection for hematuria is denied. Entitlement to service connection for chronic bronchitis is denied. Entitlement to service connection for a gastrointestinal disorder, claimed as gastroenteritis, is denied. ____________________________________________ BARBARA B. COPELAND Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs