Citation Nr: 1016154 Decision Date: 05/03/10 Archive Date: 05/13/10 DOCKET NO. 06-22 353 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder to include posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for hypertension. 3. Entitlement to service connection for a heart disorder, including as secondary to hypertension. 4. Entitlement to service connection for skin cancer. 5. Entitlement to service connection for a sinus disorder. 6. Entitlement to service connection for a gastric disorder. 7. Entitlement to service connection for bilateral hearing loss. REPRESENTATION Appellant represented by: Vietnam Veterans of America ATTORNEY FOR THE BOARD C. L. Wasser, Counsel INTRODUCTION The Veteran served on active duty in the U.S. Navy from September 1973 to September 1980. This case comes to the Board of Veterans' Appeals (Board) on appeal from a March 2005 decision by the RO in Waco, Texas. The Board notes that the RO denied an increase in a 40 percent rating for a service-connected low back disability in its March 2005 rating decision. The Veteran submitted a notice of disagreement in June 2005, and the RO issued a statement of the case in May 2006. As a timely substantive appeal has not been received from the Veteran as to this issue, it is not in appellate status and will not be addressed by the Board. 38 C.F.R. § 7105 (West 2002); 38 C.F.R. §§ 20.200, 20.202, 20.302 (2009). The issues of service connection for a gastric disorder, a sinus disorder, and bilateral hearing loss are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The credible evidence of record does not indicate that the Veteran has a current diagnosis of PTSD. 2. An acquired psychiatric disorder, to include bipolar disorder and depression, began many years after active duty and was not caused by any incident of service. 3. Hypertension began many years after active duty and was not caused by any incident of service. 4. A heart disorder began many years after active duty and was not caused by any incident of service, and service connection is not in effect for hypertension. 5. The preponderance of the evidence indicates that the Veteran's skin cancer began many years after service and is not related to active service. CONCLUSIONS OF LAW 1. A psychiatric disability, including PTSD, was not incurred in active service, nor may such disability be presumed to have been incurred in service. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2009). 2. Hypertension was not incurred in or aggravated during active service, nor may the service incurrence of hypertension be presumed. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.303, 3.307, 3.309, (2009). 3. A heart disorder was not incurred in or aggravated during active service and is not proximately due to or the result of a service-connected hypertension, nor may the service incurrence of a heart disorder be presumed. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2009). 4. Skin cancer was not incurred in or aggravated by active service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2009). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Notice and Assistance Upon receipt of a complete or substantially complete application for benefits and prior to an initial unfavorable decision on a claim by an agency of original jurisdiction, VA is required to notify the appellant of the information and evidence not of record that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159; Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The notice should also address the rating criteria or effective date provisions that are pertinent to the appellant's claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The RO provided the appellant pre-adjudication notice by letters dated in May 2004, July 2004, and September 2004. Post-adjudication notice was sent by letters dated in November 2005 and March 2006. Additional notice was sent regarding the PTSD claim in April 2006 and February 2008, and the claims were readjudicated in supplemental statements of the case dated in April and October 2008. Mayfield, 444 F.3d at 1333. VA has obtained service treatment records, assisted the appellant in obtaining evidence, afforded the appellant physical examinations, obtained medical opinions as to the etiology and severity of disabilities. As to the claims for service connection for hypertension, a heart disorder and skin cancer, the Board notes that a VA examination has not been scheduled with respect to these claims. However, in the absence of a disease, injury or event in service and a current condition, a VA examination is not required. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Veteran's representative asserts that the two VA examinations for PTSD were inadequate as the examiners did not sufficiently discuss the Veteran's diagnosis of PTSD by treating physicians. In this regard, the Board notes that both VA examiners reviewed the claims file and the Veteran's treatment records, examined the Veteran, considered the Veteran's statements regarding continuity of symptomatology, described the Veteran's disability in sufficient detail, and provided a rationale for the conclusions reached. See Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007) (finding that an examination report is adequate where it describes the disability in sufficient detail so the Board can make a fully informed evaluation of the disability). The Board finds that these examinations were adequate. With respect to the claim for service connection for skin cancer, although the RO sent many letters to the Veteran requesting that he submit pertinent medical evidence, and provided him with blank authorization forms in order to enable the RO to obtain such records, the Veteran has not submitted pertinent medical records of treatment for skin cancer. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991) (holding that the duty to assist is not always a one-way street and if a Veteran desires help with his claim he must cooperate with VA's efforts to assist him). All known and available records relevant to the issues on appeal have been obtained and associated with the appellant's claims file; and the appellant has not contended otherwise. VA has substantially complied with the notice and assistance requirements and the appellant is not prejudiced by a decision on the claims at this time. Law and Regulations Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Evidence of continuity of symptomatology from the time of service until the present is required where the chronicity of a condition manifested during service either has not been established or might reasonably be questioned. 38 C.F.R. § 3.303(b). Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). In order to prevail on the issue of service connection there must be competent evidence of a current disability; medical evidence, or in certain circumstances, lay evidence of in- service occurrence or aggravation of a disease or injury; and competent 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); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). Moreover, where a veteran served continuously for 90 days or more during a period of war, or during peacetime service after December 31, 1946, and a psychosis, cardiovascular- renal disease (including hypertension) or malignant tumors become manifest to a degree of 10 percent within one 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. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 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, 1 Vet. App. at 54. The Board has reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims file shows, or fails to show, with respect to the claims. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Acquired Psychiatric Disorder to include PTSD The Veteran essentially contends that he is entitled to service connection for PTSD that is due to stressful incidents he was exposed to during service. Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a) (i.e., Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)); a link, established by medical evaluation, between current symptoms and an in- service stressor; and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f). If the evidence establishes that the Veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with circumstances, conditions, or hardships of the Veteran's service, the Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304(f); West v. Brown, 7 Vet. App. 70 (1994). If the Veteran did not engage in combat with the enemy, or if the claimed stressors are not related to combat, the Veteran's testimony alone is not sufficient to establish the occurrence of the claimed stressors, and those stressors must be corroborated by credible supporting evidence. Cohen v. Brown, 10 Vet. App. 128 (1997). Service department records must support, and not contradict, the claimant's testimony regarding non-combat stressors. Doran v. Brown, 6 Vet. App. 283 (1994). If a PTSD claim is based on in-service personal assault, then evidence from sources other than the Veteran's service records may corroborate the Veteran's account of the stressor incident, such as: records from law enforcement authorities, rape crisis centers, mental health counseling centers, hospitals, or physicians; pregnancy tests or tests for sexually transmitted diseases; statements from family members, roommates, fellow service members, or clergy; and evidence of behavior changes following the claimed assault (including a request for a transfer to another military duty assignment; deterioration in work performance; substance abuse; episodes of depression, panic attacks, or anxiety without an identifiable cause; or unexplained economic or social behavior changes). 38 C.F.R. § 3.304(f)(4). The Veteran's service personnel records reflect that he served in the Navy and his rate was AZ3. He served in Patrol Squadron 46 (a maritime patrol squadron and aircraft squadron) in the Pacific Fleet from January 1974 to December 1976, and in Texas at Naval Air Stations from January 1977 to September 1980. He did not receive any combat citations. The Veteran's service treatment records reflect that on entrance medical examination in September 1973, his psychiatric evaluation was clinically normal. In a September 1973 report of medical history, the Veteran reported a history of depression or excessive worry, and said he did not know if he had a history of nervous trouble. In a report of medical history apparently completed in September 1976, the Veteran denied a history of depression, excessive worry, and nervous trouble. In April 1977, the Veteran was involved in a motor vehicle accident in which his car struck a tree. There was no loss of consciousness, and an evaluation showed no head injury. He suffered fractures of the right distal tibia, right lateral malleolus, left calcaneus, and left medial malleolus. The Veteran was hospitalized until early September 1977. In a November 1977 statement, he said that on the night of the accident he helped a friend to move, was tired, and began to drive home at about 10:00 in the evening. He said when he arrived in town, he drove down a boulevard and had the accident. He said he did not recall the accident when he woke up in the hospital. An incomplete sick call note dated in October 1978 reflects that the Veteran reported that he was nervous. On separation examination in August 1980, the Veteran's psychiatric evaluation was clinically normal. Service treatment records are negative for a diagnosis of a chronic psychiatric disorder. In December 1980, the Veteran filed a claim for service connection for leg injuries incurred in a motor vehicle accident in service. He did not report a psychiatric disorder. On VA examination in January 1981, the Veteran did not complain of any psychiatric symptoms. On examination, the examiner observed that the Veteran had adequate emotional behavior. A psychiatric disorder was not diagnosed. A March 1999 treatment note by G.W.W., MD, reflects that the Veteran was seen for complaints of back pain after an injury. He indicated that the Veteran showed no evidence of hysteria, anxiety, depression or substance abuse. At an August 2001 VA examination performed to evaluate his service-connected leg disabilities, the Veteran reported that he had severe pain for the past two years. He reported that he suffered a back injury when he was attacked by a dog, and underwent back surgery in October 1999. He said he had been taking anti-depressant medication for the past two years. Private medical records reflect treatment for depression from 2000 to 2007. In February 2004, the Veteran was treated for anxiety. In July 2004, the Veteran submitted a claim for service connection for PTSD. He did not identify any traumatic events in service. The RO sent him letters in September 2004 and April 2006 asking for this information. In July 2006, the Veteran responded, and reported that he was in an automobile accident during service. He said he still did not know how, when, or why the accident occurred. He said he spent a year or more at the Naval Hospital. He asserted that since the accident he had memory impairment, his spelling was worse, and he had depression and nightmares about the accident. A June 2006 VA preventive health screening note reflects that the Veteran denied experiencing military sexual trauma in the past. A PTSD screen was negative. At a July 2006 VA mental health consult, the Veteran reported that he had been having nightmares about an accident he had in 1978. He reported that he had mood swings for some time, but especially in the past two years. He said he spent a lot of his life drunk, but had sobered up, relatively speaking, in the past 10 years. He reported a prior hospitalization for cocaine addiction and alcoholism. He said he had no cocaine for six months. He denied a history of abuse either as a child or as an adult. He reported the following: combat exposure of chasing Russian submarines for hours, a severe motor vehicle accident in 1978, and said he was a victim of military sexual trauma. The examiner noted that a PTSD screen showed that the Veteran met the criteria for PTSD. The Veteran said he used to drink all the time, but now drank 2 to 4 drinks a day at most. The Axis I diagnoses were PTSD and bipolar II disorder. In an addendum, the examiner noted that the Veteran reported that he had flashbacks of the "1978" accident and the "year long" recovery in the hospital, and also had nightmares. He denied flashbacks related to his military sexual trauma, though he did report being coerced into unwanted sexual activity by superiors. He reported periods of hypomania and depression. Subsequent VA medical records reflect treatment for psychiatric complaints variously diagnosed as bipolar disorder and PTSD. On VA examination for PTSD in March 2007, the examiner reviewed the claims folder and the Veteran's electronic medical records, did psychological testing, and performed a detailed examination. The Veteran reported that he did not see combat. The examiner noted that the Veteran had been receiving VA outpatient treatment for bipolar symptoms. The examiner noted several inconsistencies in the Veteran's reported history on various examinations. The Veteran reported that he was in a car accident in service, and also reported that during service, a superior forced him to have sex. He said he felt helpless and continued to engage in sexual activity with this person throughout his military career. Various symptoms were described and a mental status examination was performed. The examiner noted that the Veteran's score on a diagnostic test showed that the Veteran had a tendency to highly exaggerate his symptoms. The Axis I diagnoses were alcohol dependence, cocaine dependence, and bipolar II disorder. The examiner concluded that the Veteran did not meet the criteria for a diagnosis of PTSD. He also noted that although the Veteran reported that he lost consciousness and had cuts and bruises on his head after the in-service car accident, a concurrent service medical note showed no upper body injuries and no loss of consciousness. He concluded that this inconsistency, psychological testing showing exaggeration, and the Veteran's observed histrionic personality traits, brought the credibility of his reported symptoms in question. The examiner opined that the Veteran's bipolar II disorder and ongoing substance abuse appeared to be pre-existing conditions and were not specifically related to military service. In a November 2007 statement, the Veteran said that he felt that sexual abuse was at the core of his PTSD. He enclosed statements from his employer and pastor to the effect that he did not currently have substance abuse problems. In February 2008, the RO sent the Veteran a letter asking him to provide further information about his reported personal assault incident(s) in service. He did not respond. On VA examination for PTSD in September 2008, the examiner reviewed the claims folder and the Veteran's medical records, did psychological testing, and performed a detailed examination. He noted that the Veteran's attending psychiatrist indicated that the Veteran's last reported cocaine use was in December 2007. During the examination, the Veteran reported that during service, a chief petty officer, H., his superior officer, made sexual advances toward him. He said H. threatened to make his life miserable if he did not comply with these advances. He said he permitted H. to engage in oral sex, and then subsequently H. repeatedly ordered him to come to his place. The Veteran reported that over time he began to enjoy it and grew quite affectionate with H. He said that after a few months of this he began attending wild orgies of gay sex and drugs with other service members, and that if he did not participate, he would be given undesirable duties. He said that his life was never threatened or in danger. The examiner opined that these unverified events did not meet criterion A in the DSM- IV definition of PTSD. The examiner found that the Veteran's motor vehicle accident did meet criterion A in the DSM-IV definition of PTSD. The Veteran said he felt psychologically traumatized by the reported military sexual trauma, but did not report that he was psychologically traumatized by the motor vehicle accident. The Veteran reported a long history of symptoms of bipolar disorder and drug abuse, and said he had lived with his partner in a homosexual relationship for 25 years. The examiner administered the structured inventory of malingered symptomatology (SIMS), and noted that the Veteran's score on this test suggested that the Veteran may have exaggerated his symptoms, which raised the question of whether he is credible. The examiner found that the Veteran reported a few symptoms of PTSD but did not meet the full criteria for a diagnosis. The examiner opined that the vast majority of the Veteran's symptoms were associated with his bipolar condition and he did not meet the criteria for a diagnosis of PTSD. The Axis I diagnoses were bipolar II disorder, alcohol abuse, and cocaine dependence, reportedly in remission. The examiner opined that the Veteran's history suggested that his bipolar condition had a strong genetic loading, as multiple family members had been diagnosed with bipolar disorder and/or schizophrenia. The examiner opined that the Veteran's diagnoses of bipolar II disorder, alcohol abuse, and cocaine dependence were not at least as likely as not secondary to his military service. Evidence weighing against the claim includes the fact that the service treatment records are negative for complaints, treatment, or diagnosis of a psychiatric disorder. Moreover, there is no medical evidence of a psychiatric disorder for many years after separation from service. The first documented psychiatric disorder was in 2000, approximately 20 years after service. The first diagnosis of PTSD was in 2006. In this regard, evidence of a prolonged period without medical complaint, and the amount of time that elapsed since military service, can be considered, along with other factors, as evidence of whether an injury or disease was incurred in service which resulted in any chronic or persistent disability. See Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). Moreover, two VA examiners have found that the Veteran does not meet the diagnostic criteria for a diagnosis of PTSD. Both examiners also found that the Veteran's credibility was questionable. In reaching these conclusions, both examiners thoroughly reviewed the Veteran's claims file and examined the Veteran, considered the Veteran's statements regarding continuity of symptomatology, described the Veteran's disability in sufficient detail, and provided a rationale for the conclusions reached. See Stefl, supra. In its assessment of medical evidence, the Board can favor some medical evidence over other medical evidence so long as the Board adequately explains its reasons for doing so. See Wensch v. Principi, 15 Vet. App. 362, 367 (2001); Evans v. West, 12 Vet. App. 22, 30 (1998); Owens v. Brown, 7 Vet. App. 429, 433 (1995). The Board finds that the March 2007 and September 2008 VA examination reports finding that PTSD is not shown are more probative than the outpatient treatment records which diagnosed the Veteran with PTSD, as they thoroughly reviewed the claims file and treatment records (including the noted outpatient treatment records), administered extensive psychological testing, and performed clinical evaluations. Moreover, the Board finds that the Veteran's credibility is questionable as to his alleged stressor of military sexual trauma, and observes that his reported history and reported symptoms have been markedly inconsistent. The existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C.A. § 1110; see Degmetich v. Brown, 104 F. 3d 1328 (1997) (holding that the VA's and the United States Court of Appeals for Veterans Claims interpretation of section 1110 of the statute as requiring the existence of a present disability for VA compensation purposes cannot be considered arbitrary and therefore the decision based on that interpretation must be affirmed); see also, Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 144 (1992). The Board finds that the preponderance of the evidence demonstrates that the Veteran does not currently have PTSD related to an in-service stressor. Furthermore, there is no medical evidence linking the Veteran's current psychiatric disorders (bipolar disorder and depression) with service, and no evidence of a psychosis within the first post-service year. As a lay person, the Veteran cannot provide a competent opinion that his current psychiatric disorder is causally related to service. The evidence of the passage of so many post-service years before documentation of a psychiatric disorder along with normal findings on the separation examination contradicts his assertions that he has had a psychiatric disorder since service, and, therefore, the statements that he has had a continuity of symptomatology since service are not credible and carry no probative weight. See Buchanan, supra; Maxson, supra. The Board finds that the Veteran's statements as to continuity of symptomatology of a psychiatric disorder since service are simply not credible. In summary, the record fails to show competent and probative evidence of an acquired psychiatric disorder (to include PTSD) in service or for many years thereafter, and the preponderance of the evidence is against a finding that the condition is due to or aggravated by service. Therefore, the Board finds that the preponderance of the evidence is against the claim, and the appeal must therefore be denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 51. Hypertension The Veteran contends that he incurred hypertension in service. His representative has asserted that the Veteran was "pre-hypertensive" in service. Service treatment records reflect that on entrance examination in September 1973, the Veteran's blood pressure was 118/76. On examination in September 1976, his blood pressure was 118/82. In a September 1973 report of medical history, the Veteran said he did not know if he had a history of high or low blood pressure. In November 1978, his blood pressure was 128/88. On separation examination in August 1980, the Veteran's blood pressure was 122/70. Service treatment records are negative for a diagnosis of hypertension. For VA compensation purposes, the term "hypertension" means that the diastolic blood pressure is predominantly 90mm. or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160mm. or greater with a diastolic blood pressure of less than 90mm. 38 C.F.R. § 4.104, Diagnostic Code 7101, Note 1. With this in mind, it is noted that there is no competent medical evidence of elevated blood pressure readings or other indicia of hypertension shown in service treatment records for the Veteran's period of active duty from September 1973 to September 1980. At a January 1981 VA examination, the Veteran's blood pressure was 120/86. The Veteran's medical records are negative for hypertension until 2000. A January 2000 VA outpatient treatment record reflects that the Veteran's blood pressure was 136/96. In June 2001, it was 156/105. Further evaluation was recommended. Private medical records dated from 1999 reflect treatment for a variety of conditions. Treatment notes dated in March and April 2000 reflect blood pressure readings of 122/84 and 122/82, respectively. Later in April 2000 his blood pressure was 136/94. A June 2000 outpatient note reflects a diagnosis of hypertension. In December 2000 he was diagnosed with intermittent hypertension. Hypertension was not diagnosed until the 2000s, much more than a year after separation from the Veteran's period of active duty service. There is no medical evidence linking the Veteran's hypertension with active duty service. As to a causal relationship between his current hypertension and service, the Veteran is not qualified to offer an opinion because the question of etiology of his hypertension is not lay-observable and requires medical expertise. In this regard, the Board finds that a lay person is not competent to offer an opinion on a matter clearly requiring medical expertise, such as opining that his current hypertension is related to service. See Jandreau, supra. Therefore, this is not a case in which the Veteran and his representative's lay beliefs alone can serve to establish any association between the current hypertension and his military service. See Espiritu v. Derwinski, 2 Vet. App. 492 (1992); Moray v. Brown, 5 Vet. App. 211 (1993). The evidence of the passage of several post-service years before documentation of hypertension along with normal findings on the August 1980 separation examination and on the January 1981 VA examination contradict his assertions that he has had hypertension since separation in September 1980, and, therefore, the statements that he has had a continuity of symptomatology since service are not credible and carry no probative weight. See Buchanan, supra; Maxson, supra. In summary, the record fails to show competent and probative evidence of hypertension in service or for years thereafter, and the preponderance of the evidence is against a finding that the condition is due to or aggravated by service. Therefore, the Board finds that the preponderance of the evidence is against the claim, and the appeal must therefore be denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 51. Heart Disorder The Veteran essentially contends that he has a heart disorder due to his hypertension. Service connection may be established for disability which is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a). Further, a disability which is aggravated by a service-connected disability may be service-connected to the degree that the aggravation is shown. 38 C.F.R. § 3.310(b); Allen v. Brown, 7 Vet. App. 439 (1995). The Board notes that VA amended its regulation pertaining to secondary service connection during the pendency of this appeal, effective from October 10, 2006. See 71 Fed. Reg. 52,744 (2006) (codified at 38 C.F.R. § 3.310). However, as discussed below, the secondary service connection claim for a heart disorder is on the basis of a link to hypertension. Since service connection for hypertension is herein denied, either version of 38 C.F.R. § 3.310 is of no avail to the claim. On entrance medical examination in September 1973, the Veteran's heart was clinically normal. A September 1973 chest X-ray study was negative. In a September 1973 report of medical history, the Veteran denied a history of heart trouble or chest pain or pressure. Service treatment records are negative for a heart disorder. On separation examination in August 1980, the Veteran's heart was clinically normal, and a chest X-ray study was within normal limits. On VA examination in January 1981, the Veteran's heart had a regular rate and rhythm, with no murmur. A June 2000 private medical record reflects that the Veteran was diagnosed with hypertension. The physician noted that the Veteran's heart had a regular rate and rhythm with no extra sounds or murmurs. A July 2002 private medical record reflects a diagnostic assessment of tachycardia. In July and September 2002 he was diagnosed with paroxysmal supraventricular tachycardia. In March 2003 he was diagnosed with new atrial fibrillation. An April 2003 private chest X-ray study showed no cardiac abnormalities other than mild tortuosity of the aorta. A July 2004 treatment note from Advanced Heart Care reflects that the Veteran was seen for management of hypertension and dyslipidemia. It was noted that he underwent successful radiofrequency ablation for atrial flutter in December 2003. The Veteran denied recurrent palpations. A June 2006 VA chest X-ray study showed a normal heart. Private electrocardiograms dated in August 2006 showed sinus bradycardia. In sum, service treatment records from the Veteran's period of active duty are negative for a diagnosis of a heart disorder, and the Veteran's heart was normal on separation examination in August 1980. Post-service medical records are negative for any heart disorder until 2002. The Veteran cannot provide a competent opinion that he has a heart disorder that is causally related to military service. The Veteran does not contend, and the medical evidence does not reflect, that a heart disorder was incurred in service. To the extent that the Veteran is claiming secondary service connection for a heart disorder as related to hypertension, the Board cannot grant such claim since service connection is not in effect for hypertension. In summary, the record fails to show competent and probative evidence of a heart disorder in service or for years thereafter, and the preponderance of the evidence is against a finding that the condition is due to or aggravated by service. Therefore, the Board finds that the preponderance of the evidence is against the claim, and the appeal must therefore be denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. Skin Cancer The Veteran essentially contends that he incurred skin cancer of the face due to sun exposure in service. On entrance medical examination in September 1973, the Veteran's skin was clinically normal. In a September 1973 report of medical history, the Veteran gave a history of skin diseases; the reviewing examiner noted that the Veteran had a history of acne. In January 1975 the Veteran was seen for herpes simplex lesions on his lower lip. In September 1977 the Veteran was treated for complaints of a rash on his hands; the diagnosis was dyshidrotic eczema. In May 1978, the Veteran was treated for itching and small red spots on his body; the diagnosis was dyshidrosis. On separation examination in August 1980, the Veteran's skin was clinically normal. Service treatment records are negative for skin cancer. On VA examination in January 1981, an examination of the Veteran's head, face, and neck showed no masses. An examination of his skin revealed no lesions. A February 2004 private medical record from Advanced Heart Care noted that the Veteran reported that he recently underwent left eye surgery for basal cell carcinoma at Texas Cancer Center. Records of such treatment are not on file. Subsequent medical records also reflect that the Veteran reported that he was undergoing surgery to remove facial lesions. In November 2007, the Veteran contended that he incurred skin cancer due to standing in formation without sunscreen during service in Orlando, Florida. He said his dermatologist told him that "all skin cancer is a result of what we did when we were young." In sum, service treatment records are entirely negative for cancer, including skin or eye cancer. Although the Veteran is competent to state that he stood in the sun during service, he is not competent to opine as to the etiology of any current skin cancer. See Espiritu, 2 Vet. App. at 495. With respect to the Veteran's report of statements by his dermatologist (the records of whom are not on file), the Board notes that service connection may not be based on a resort to pure speculation or even remote possibility. See 38 C.F.R. § 3.102. There is no medical evidence linking the post-service skin cancer to service. The weight of the competent and credible evidence demonstrates that the Veteran's apparent skin cancer began many years after his active duty and was not caused by any incident of service. As the preponderance of the evidence is against the claim for service connection for skin cancer, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 51. ORDER Service connection for an acquired psychiatric disorder, to include PTSD, is denied. Service connection for hypertension is denied. Service connection for a heart disorder is denied. Service connection for skin cancer is denied. REMAND Although further delay is regrettable, the Board finds that further development is required prior to adjudication of the Veteran's claims for service connection for a sinus disorder, a gastric disorder, and bilateral hearing loss. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. With respect to the claim for service connection for a sinus disorder, the Board notes that in a September 1973 report of medical history, he reported a history of hay fever, chronic or frequent colds, and ear, nose or throat trouble. The reviewing examiner noted that the Veteran had a history of hay fever with no sequelae. On entrance medical examination in September 1973, the Veteran's nose and sinuses were clinically normal. Service dental records reflect that the Veteran reported that he had allergies, hay fever, and sinus trouble. Service treatment records reflect episodic treatment for sinus/nasal congestion, hay fever, allergic reaction (sinusitis), allergic rhinitis, and upper respiratory infections. On separation examination in August 1980, the Veteran's nose and sinuses were clinically normal. The Board notes that a veteran will be presumed to have been in sound condition when examined, accepted, and enrolled in service, except as to defects, infirmities, or disorders noted at entrance into service. Only such conditions as are recorded in examination reports are to be considered as noted. Clear and unmistakable (obvious or manifest) evidence demonstrating that an injury or disease existed prior to service will rebut the presumption of soundness. 38 U.S.C.A. § 1111; 38 C.F.R. § 3.304. The Veteran has stated that he has had sinus problems since service. Recent medical records reflect treatment for sinusitis, allergies, and asthma. (See private medical records dated in May 2001 and January 2002, and a December 2003 private computed tomography scan of the Veteran's sinuses.) In sum, the record includes the Veteran's reports of sinus symptoms ever since service, a recent diagnosis of sinusitis, service treatment records showing treatment for nasal/sinus complaints, and evidence that sinus problems and/or hay fever may have preexisted service. An examination with respect to the etiology of the Veteran's current sinus disorder, to include whether any pre-existing sinus disorder was aggravated by service, is necessary to decide this claim. See McLendon, 20 Vet. App. at 79; 38 C.F.R. § 3.159(c)(4). With respect to the claim for service connection for gastritis, the Board finds that a VA examination is necessary to make a decision on this claim. In August 1974, the Veteran was treated for complaints of stomach trouble and vomiting blood. The examiner's impression was that the vomiting was caused by chronic coughing. In September 1974, the Veteran was treated for complaints of abdominal cramps for three days with diarrhea and vomiting; the diagnostic impression was gastroenteritis. In November 1978, the Veteran reported that he vomited blood three times the previous day and once that morning; the diagnostic assessment was probable Mallory-Weiss [syndrome]. In December 1979, the Veteran was treated for complaints of nausea and vomiting. In May 1980 he was treated for complaints of nausea, headache, general malaise, mild diarrhea and sinus problems. The diagnostic assessment was viral syndrome. In August 1980, the Veteran was seen for complaints of diarrhea and upper respiratory symptoms for one day. On examination, there were increased bowel sounds with no tenderness. The pertinent diagnostic impression was "gastrititisis." Service treatment records are negative for a diagnosis of a chronic gastric or stomach disorder. At a January 1981 VA examination, the Veteran's abdomen was soft, non-tender and there was no organomegaly. There were no gastrointestinal complaints or diagnoses. Recent medical evidence reflects treatment for gastroesophageal reflux disease (GERD) and duodenitis. In sum, the record includes the Veteran's reports of gastric symptoms ever since service, a recent diagnosis of GERD, and service treatment records showing treatment for gastric complaints. An examination with respect to the etiology of any current gastric disorder is necessary to decide this claim. McLendon, supra; 38 C.F.R. § 3.159(c)(4). Further, in light of the Veteran's in-service diagnosis of Mallory-Weiss syndrome, and post-service treatment records reflecting a long history of alcohol abuse as well as gastric complaints, the examiner should also be asked to opine as to whether any current gastric disorder is related to alcohol abuse. Direct service connection may be granted only when a disability was incurred or aggravated in the line of duty, and not the result of the veteran's own willful misconduct or, for claims filed after October 31, 1990, the result of his or her abuse of alcohol or drugs. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.301. With respect to the Veteran's claim for service connection for bilateral hearing loss, he contends that he has bilateral hearing as a result of his service in the U.S. Navy including exposure to the noise from airplanes. For the purposes of applying the laws administered by the VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies of 500, 1,000, 2,000, 3,000 and 4,000 Hertz is 40 decibels or greater; or when the thresholds for at least three of these frequencies are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. Audiometric testing on enlistment examination in September 1973 revealed right ear decibel thresholds of 25, 20, 5, 15, and 25, and left ear decibel thresholds of 25, 20, 15, 15, and 25, at the respective frequencies of 500, 1000, 2000, 3000, and 4000 hertz. Audiometric testing on examination in September 1976 revealed right ear decibel thresholds of 20, 15, 5, 15, and 25, and left ear decibel thresholds of 5, 5, 5, 10, and 10, at the respective frequencies of 500, 1000, 2000, 3000, and 4000 hertz. Audiometric testing on separation examination in August 1980 revealed right ear decibel thresholds of 15, 10, 0, 10, and 25, and left ear decibel thresholds of 15, 5, 10, 15, and 15, at the respective frequencies of 500, 1000, 2000, 3000, and 4000 hertz. On VA examination in January 1981, the examiner indicated that hearing loss was not noted. Private medical records from D.M.C., MD, Ph.D. dated in January 2006, including a private audiological examination, reflect that the Veteran reported that he was exposed to noise from jet engines in service, and also played in a rock band in service. Dr. C. opined that the Veteran's hearing loss was "contributed to" by exposure to excessive military noise. He diagnosed bilateral mixed mild to moderate hearing loss and tinnitus with a conductive component secondary to thickened tympanic membranes, and a sensorineural component more likely than not at least partially due to military service. At a VA examination in August 2007, the examiner noted that the Veteran's hearing thresholds at the time of separation from service were within normal limits, and found that current hearing loss was not likely related to acoustic trauma in service. The examiner also commented on the private medical records from Dr. C. and noted that such records indicated that he did not review veterans' military records. The VA examiner's opinion is based, at least in part, on the "normal" in-service audiogram findings. However, the requirements for service connection for hearing loss as defined in 38 C.F.R. § 3.385 need not be shown by the results of audiometric testing during a claimant's period of active military service in order for service connection to be granted. See Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992); Hensley v. Brown, 5 Vet. App. 155, 159 (1993). Under these circumstances the Board finds that another VA medical opinion is necessary to determine whether the Veteran's current hearing loss was incurred in or aggravated by service. 38 U.S.C.A. § 5103A(d); Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Ongoing medical records should also be obtained. 38 U.S.C.A. § 5103A(c); see also Bell v. Derwinski, 2 Vet. App. 611 (1992) (VA medical records are in constructive possession of the agency, and must be obtained if the material could be determinative of the claim). Accordingly, the case is REMANDED for the following action: 1. Obtain pertinent VA and private medical records regarding a sinus disorder, a gastric disorder, or hearing loss that are not already on file, and associate them with the claims file. Complete this action before scheduling the Veteran for examinations. 2. After completion of the foregoing, schedule the Veteran for an appropriate VA examination to determine the current nature and likely etiology of any current nose and/or sinus disorder. The claims folder should be made available to the examiner for review in conjunction with the examination. Based on the examination and review of the record, the examiner is asked to answer the following questions: (a) Does the evidence of record clearly and unmistakably show that the Veteran had hay fever, or a nose or sinus disorder that existed prior to his entry onto active duty? (b) If the answer is yes, does the evidence clearly and unmistakably show that the preexisting condition was not aggravated by service? (c) If the answer is no, is it at least as likely as not that the current sinus disorder had its onset in service? A rationale for all opinions expressed should be provided. If the examiner cannot reach a conclusion without resorting to speculation, it should be so stated in the examiner's report. 3. Schedule the Veteran for an appropriate VA examination to determine the current nature and likely etiology of any current gastric disorder. The claims folder should be made available to the examiner for review in conjunction with the examination. Based on the examination and review of the record, the examiner is asked to answer the following questions: (a) Is it at least as likely as not (i.e., a 50 percent or higher degree of probability) that any current gastric disorder was incurred in service? (b) Is any current gastric disorder related to alcohol abuse? A rationale for all opinions expressed should be provided. If the examiner cannot reach a conclusion without resorting to speculation, it should be so stated in the examiner's report. 4. The RO/AMC should obtain a VA medical opinion to determine the current nature and likely etiology of the current hearing loss. The claims folder should be made available to the medical professional for review. The examiner is requested to review all pertinent records associated with the claims file, including service treatment records. Based on the review of the record, the medical professional should answer the following question: Is it at least as likely as not (i.e., a 50 percent or higher degree of probability) that any currently demonstrated hearing loss is causally related to the Veteran's active duty service, to include noise exposure? A rationale for all opinions expressed should be provided. 5. After the development requested above has been completed to the extent possible, the RO should again review the record, including any additional evidence received since the last supplemental statement of the case. If the Veteran's claims remain denied, the appellant and his representative should be furnished a supplemental statement of the case and given the opportunity to respond before this case is returned to the Board. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2009). ______________________________________________ M. E. LARKIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs