Citation Nr: 1136870 Decision Date: 09/30/11 Archive Date: 10/11/11 DOCKET NO. 07-37 176 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Buffalo, New York THE ISSUES 1. Entitlement to service connection for hypertension, claimed as secondary to service-connected fibromyalgia. 2. Entitlement to service connection for cardiovascular signs and symptoms, to include as due to an undiagnosed illness. 3. Entitlement to service connection for a skin condition, claimed as due to exposure to radiation and chemicals. 4. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) and an unspecified "nerve condition," claimed as due to exposure to chemicals and ionizing radiation. REPRESENTATION Appellant represented by: New York State Division of Veterans' Affairs ATTORNEY FOR THE BOARD D. M. Ames, Counsel INTRODUCTION The Veteran had active service from September 1989 to September 1993. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Reno, Nevada and a January 2008 rating decision of the VA RO in Huntington, West Virginia, to which the claims file was temporarily brokered by the Buffalo, New York RO. Jurisdiction of the Veteran's claims file was transferred to the Buffalo RO after the June 2006 rating decision was issued. The June 2006 rating decision denied service connection for hypertension and a cardiovascular condition. The January 2008 rating decision denied service connection for a nerve condition, a skin condition, and PTSD. The Board has rephrased the Veteran's claim for PTSD as one claim for entitlement to service connection for an acquired psychiatric disorder, to include PTSD and an unspecified "nerve condition," claimed as due to exposure to chemicals and radiation. See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (stating that the scope of a mental health disability claim includes any mental disability that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record). The issues of entitlement to service connection for hypertension, a skin condition, and an acquired psychiatric disorder 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. All relevant evidence necessary for an equitable disposition of the Veteran's appeal has been obtained. 2. The competent and probative medical and other evidence of record does not demonstrate that the Veteran has cardiovascular signs and symptoms or a cardiovascular condition. CONCLUSION OF LAW The criteria for the establishment of service connection for a cardiovascular condition are not approximated. 38 U.S.C.A. §§ 1110, 1117, 1131, 5103, 5103A, 5017 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.303, 3.310, 3.317 (2011). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Duty to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2011). A. Duty to Notify Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant of the information and evidence not of record that is necessary to substantiate the claim, and to indicate which information and evidence VA will obtain and which information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). VCAA notice requirements apply to all five elements of a service connection claim, including: (1) Veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 486 (2006). The notice provided by VA must be given prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006) (Mayfield II); Pelegrini v. Principi, 18 Vet. App. 112 (2004) (Pelegrini II). However, if VCAA notice was not provided prior to the initial adjudication of the claim or, if provided, was inadequate or incomplete, such an error can be "cured" by providing any necessary notice and then readjudicating the claim, including in a Statement of the Case (SOC) or Supplemental Statement of the Case (SSOC), such that the intended purpose of the notice is not frustrated and the Veteran is given ample opportunity to participate effectively in the adjudication of the claim. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007) (Mayfield IV); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). Defective timing or content of VCAA notice is not prejudicial to a claimant if the error does not affect the essential fairness of the adjudication. Sanders v. Nicholson, 487 F.3d 881, 889 (Fed. Cir. 2007), rev'd on other grounds, Shinseki v. Sanders, 29 S.Ct. 1696 (2009). VA has satisfied its VCAA duty to notify by issuing a predecisional notice letter for cardiovascular signs and symptoms in May 2005. In that letter, the RO notified the Veteran of the evidence needed to substantiate his claims for service connection. The letter also satisfied the second and third elements of the duty to notify by informing the Veteran that VA would make reasonable efforts to obtain medical records, employment records, or records held by other Federal agencies, but that he was nevertheless responsible for providing any necessary releases and enough information about the records to enable VA to request them from the person or agency that had them. The letter also explained how disability ratings and effective dates were determined. With regard to the Veteran's cardiovascular claim, the May 2005 letter did not notify the Veteran of the provisions of 38 C.F.R. § 3.317, which pertains to compensation for Persian Gulf Veterans with undiagnosed illnesses. However, the September 2007 statement of the case (SOC) contained the text of 38 C.F.R. § 3.317. The Veteran and his representative have not alleged any prejudice as a result of this lack of predecisional notice, nor has any been shown. See Shinseki v. Sanders 29 S.Ct. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination.). His claim was subsequently readjudciated in the September 2009 supplemental statement of the case (SSOC). See Mayfield v. Nicholson, 444 F.3d 1328, 1333-34 (Fed. Cir. 2006). B. Duty to Assist The Board finds that the duty to assist provisions of the VCAA have been met with respect to the issue being decided. All available service treatment records (STRs) and service personnel records (SPRs) have been obtained and associated with the Veteran's claims folder. Further, all relevant treatment records adequately identified by the Veteran have been procured and associated with his claims folder. The Veteran has not been afforded VA examinations to assess the nature and etiology of his claimed cardiovascular signs and symptoms. In McLendon v. Nicholson, 20 Vet. App. 79 (2006), the Veterans Court made clear that VA must provide a VA medical examination when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran's service or with another service-connected disability, but (4) insufficient competent medical evidence on file for VA to make a decision on the claim. However, a VA examination is unnecessary to decide the claims for service connection for cardiovascular signs and symptoms because such an examination would not provide any more information than is already associated with the claims file. As will be explained below, the Veteran has not been shown to have cardiovascular signs and symptoms at any time during the pendency of the appeal. Therefore, because there is no current disorder that could be related to an event, injury, or disease in service, the Board finds that a VA examination is unnecessary. 38 C.F.R. § 3.159(4)(i); cf. Duenas v. Principi, 18 Vet. App. 512, 517 (2004), citing Paralyzed Veterans of Am. V. Sec'y of Veterans Affairs, 345 F.3d 1334, 1355-57 (Fed. Cir. 2003) (noting that a medical examination conducted in connection with claim development could not aid in substantiating a claim when the record does not already contain evidence of an in-service event, injury, or disease). See also Waters v. Shinseki, 601 F. 3d 1274, 1278 (Fed. Cir. 2010) (noting that a Veteran's conclusory generalized statement that a service illness caused his present medical problems was not enough to entitle him to a VA medical examination since all Veterans could make such a statement, and such a theory would eliminate the carefully drafted statutory standards governing the provision of medical examinations and require VA to provide such examinations as a matter of course in virtually every disability case). Accordingly, the Board finds that VA has done everything reasonably possible to notify and to assist the Veteran in the development of his service connection claim. Under the circumstances of this case, additional efforts to assist the Veteran in accordance with the VCAA would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (holding that 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 and that such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the Veteran). II. Service Connection Claim Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In order to establish service connection for the claimed disorder, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical, or in certain circumstances, lay evidence of a nexus between the claimed in-service disease or injury and the current disability. See 38 C.F.R. § 3.303; see also Hickson v. West, 12 Vet. App. 247, 253 (1999); Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all of the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (finding that the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis herein focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (holding that the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). The Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The evaluation of evidence generally involves a 3-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. The Board must then determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007) (observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). The third step of this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159. Lay evidence may be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition (i.e., when the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer); (2) the layperson is reporting a contemporaneous medical diagnosis, or;(3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009) (where widow seeking service connection for cause of death of her husband, the Veteran, the Court holding that medical opinion not required to prove nexus between service connected mental disorder and drowning which caused Veteran's death). In ascertaining the competency of lay evidence, the Courts have generally held that a layperson is not capable of opining on matters requiring medical knowledge. Routen v. Brown, 10 Vet. App. 183 (1997). In certain instances, however, lay evidence has been found to be competent with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See, e.g., Barr v. Nicholson, 21 Vet. App. 303 (2007) (concerning varicose veins); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (a dislocated shoulder); Charles v. Principi, 16 Vet. App. 370 (2002) (tinnitus); Falzone v. Brown, 8 Vet. App. 398 (1995) (flatfeet). Laypersons have also been found to not be competent to provide evidence in more complex medical situations. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (concerning rheumatic fever). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). After determining the competency and credibility of evidence, the Board must then weigh its probative value. In this function, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 511-512 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table); see Madden v. Brown, 125 F.3d 1447 (Fed Cir. 1997) (holding that the Board has the "authority to discount the weight and probative value of evidence in light of its inherent characteristics in its relationship to other items of evidence"). In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to service connection for a cardiovascular condition. The Veteran claims that he has a cardiovascular condition and argues in favor of service connection on two bases. First, that it is part of an undiagnosed illness and service connection should be granted under the regulations regarding Persian Gulf Veterans. Second, he asserts that his condition is secondary to his service-connected fibromyalgia. The Board will first address service connection under the regulations regarding Persian Gulf Veterans. Service connection may be established for a Persian Gulf Veteran who exhibits objective indications of a chronic disability resulting from an undiagnosed illness that became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than September 30, 2011, and which by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C.A. § 1117, 38 C.F.R. § 3.317(a)(1). In the case of claims based on undiagnosed illness, there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Gutierrez v. Principi, 19 Vet. App. 1, 8-9 (2004). "Objective indications of chronic disability" include both "signs," in the medical sense of objective evidence perceptible to a physician, and other, non-medical indicators that are capable of independent verification. To fulfill the requirement of chronicity, the illness must have persisted for a period of six months. 38 C.F.R. § 3.317(a)(2), (3). Signs or symptoms that may be manifestations of undiagnosed illness include, but are not limited to, cardiovascular signs or symptoms. 38 C.F.R. § 3.317(b). For Persian Gulf War Veterans, service connection may be granted for objective indications of a chronic disability resulting from an illness or combination of illnesses manifested by one or more signs or symptoms. The chronic disability must have become manifest either during active military service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2011, and must not be attributed to any known clinical diagnosis by history, physical examination, or laboratory tests. 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317(a)(b). For purposes of section 3.317, a qualifying chronic disability means a chronic disability resulting from any of the following (or any combination of the following): (A) an undiagnosed illness; (B) the following medically unexplained chronic multi-symptom illnesses that are defined by a cluster of signs or symptoms: (1) chronic fatigue syndrome; (2) fibromyalgia; (3) irritable bowel syndrome; or (4) any other illness that the Secretary determines meets the criteria in paragraph (a)(2)(ii) of this section for a medically unexplained chronic multi symptom illness; or (C) any diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C.A. § 1117(d) warrants a presumption of service connection. 38 C.F.R. § 3.317(a)(2)(i). Service connection shall not be granted under 38 C.F.R. §3.317 if (1) there is affirmative evidence that an undiagnosed illness was not incurred during active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War; (2) if there is affirmative evidence that an undiagnosed illness was caused by a supervening condition or event that occurred between the Veteran's most recent departure from active duty in the Southwest Asia theater of operations during the Persian Gulf War and the onset of the illness; or (3) if there is affirmative evidence that the illness is the result of the Veteran's own willful misconduct or the abuse of alcohol or drugs. 38 C.F.R. § 3.317(c). The term "Persian Gulf Veteran" means a Veteran who served on active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War. 38 C.F.R. § 3.317(d)(1). The record shows that the Veteran is a Persian Gulf Veteran. 38 C.F.R. § 3.317(d)(2). Generally, VA does not grant service connection for symptoms alone, without an identified basis for those symptoms. For example, "pain alone, without a diagnosed or identifiable underlying malady or condition, does not in and of itself constitute a disability for which service connection may be granted." Sanchez-Benitez v. West, 13 Vet. App. 282 (1999); Evans v. West, 12 Vet. App. 22, 31-32 (1998). The notable exception to this rule is 38 C.F.R. § 3.317, which permits, in some circumstances, service connection of signs or symptoms that are objective indications of chronic disability, even though such disability is due to undiagnosed illness In this case, the Veteran asserts that he has cardiovascular signs and symptoms. However, a review of the record shows that the Veteran does not have a heart condition or cardiovascular signs and symptoms. His STRs are negative for any complaint of or treatment for a heart problem. His May 1989 entrance examination did not note a heart problem and the Veteran reported, "I am in good health." In his December 1991 chronological record of medical care, the Veteran circled "no" for "heart and circulation" as the response to the question, "during the past year have you had any problems with any of the following?" A February 1992 electrocardiographic record was within normal limits. In April 1992, he had a chest x-ray when he had a cold, and it showed his heart to be of normal size and outline, and his x-ray was radiographically negative. In his December 1992 chronological record of medical care, the Veteran again circled "no" for "heart and circulation" as the response to the question, "during the past year have you had any problems with any of the following?" In addition to not being treated for a heart condition in service, his post-service treatment records do not show a heart condition or any cardiovascular signs and symptoms. A June 2005 VA arteries and veins examination revealed that the Veteran had normal sinus rhythm without sinus arrhythmia. His chest x-ray was within normal limits. A May 2007 VA treatment record noted that the Veteran complained of shortness of breath on exertion if he bent over. This was investigated, and it was determined to be a result of his reflux. The Veteran reported a history of irregular heartbeat at the same May 2007 appointment, and the physician noted, "but this was only once and this has not recurred." The Veteran denied being told that he had a heart murmur and denied chest pain other than what was found to be a result of his reflux. On examination, he was "slightly tachycardic at 103," with no murmurs, gallops, or rubs. A June 2008 VA treatment record notes that the Veteran had no murmurs, gallops, or rubs, and he had a regular heart rate and rhythm. A September 2009 VA treatment record showed a normal heart rhythm with no murmurs. A January 2010 VA treatment record shows that he had no murmurs, gallops, or rubs. A June 2010 VA treatment record noted the same. He had a normal heart rate and rhythm. A January 2011 VA treatment record notes that a complete review of his systems was performed and found to be negative with the exception of his fibromyalgia-related pain. The record does not show that the Veteran has any cardiovascular signs or symptoms. In fact, his heart rate and rhythm have been consistently normal, and no murmurs, gallops, or rubs have been detected. The Veteran experienced slight tachycardia at one VA health care provider appointment in May 2007, and there was no indication that this was a chronic symptom instead of a single occurrence. Therefore, the claimed condition may not be service connected under 38 U.S.C.A. § 1117 and 38 C.F.R. § 3.317. The Veteran also asserts that his claimed cardiovascular condition was caused by his service-connected fibromyalgia. A disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310(a). Secondary service connection may also be established for a nonservice-connected disability which is aggravated by a service connected disability. In such an instance, the Veteran may be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.310(b) (2010); see Allen v. Brown, 7 Vet. App. 439, 448 (1995). A claim for secondary service connection requires medical evidence that connects the asserted secondary disorder to the service-connected disability. Velez v. West, 11 Vet. App. 148, 158 (1998). In order to establish entitlement to service connection on this secondary basis, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a nexus (i.e., link) between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). As discussed above, the Veteran has not been diagnosed with a heart condition. Therefore, the first element of a secondary service connection claim has not been satisfied. Id. The existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C.A. § 1110, 1131; see Degmetich, 104 F. 3d at 1332. Evidence must show that the Veteran currently has the disability for which benefits are being claimed. The medical evidence does not establish that the Veteran has complained of or been diagnosed with a cardiovascular condition. Therefore, the Board finds that the Veteran is not entitled to service connection for a cardiovascular condition on a secondary basis. 38 C.F.R. § 3.310. The Board acknowledges that the Veteran has submitted literature indicating that pain medication, such as what is taken for fibromyalgia, can cause cardiovascular problems. However, it is not afforded probative weight in this case because the Veteran has not been diagnosed with a cardiovascular condition. Further, generic medical literature which does not apply medical principles regarding causation or etiology to the facts of an individual case does not provide competent evidence to establish a nexus. See Libertine v. Brown, 9 Vet. App. 521, 523 (1996). The exception to this competency rule is when the medical treatise information, where "standing alone, discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least plausible causality based upon objective facts rather than on an unsubstantiated lay medical opinion." Wallin v. West, 11 Vet. App. 509, 513 (1998). The treatise submitted by the Veteran proposes the hypothesis that persistent pain leads to generalized arousal and elevation of blood pressure, and concludes that "a transient increase in blood pressure can have a pain-relieving and possibly stress-relieving effect due to increased endorphin release." This article pertains to hypertension, and not a claimed heart condition. Therefore it is not competent evidence when standing on its own. Lastly, the Board will address service connection for a heart condition under the theory of direct service connection. See Combee v. Brown, 34 F.3d 1039, 1042 (Fed Cir. 1994). As noted above, the Veteran has not been diagnosed with a cardiovascular condition, and on that basis alone, his claim must fail. There is no evidence of record that he had a heart problem in service. As noted above, he denied having heart trouble in his STRs. Further, his post-service treatment records consistently show a normal heart rate and rhythm, and no murmurs, gallops, rubs, or other defects. The existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C.A. § 1110, 1131; see Degmetich, 104 F. 3d at 1332. Evidence must show that the Veteran currently has the disability for which benefits are being claimed. As medical evidence does not establish that the Veteran has complained of or been diagnosed with a cardiovascular condition, his claim must be denied. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is resolved in favor of the Veteran. 38 U.S.C.A. § 5107(b). In this case, the evidence is not in relative equipoise. Since the preponderance of the evidence is against the claim, the provisions of 38 U. S. C. A. 5107(b) regarding reasonable doubt are not applicable, and his claim must be denied under all three theories of entitlement discussed above. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Alemany v. Brown, 9 Vet. App. 518, 519 (1996). ORDER Service connection for a cardiovascular condition is denied. REMAND While the Board regrets the further delay that a remand of this case will cause, the record is not ready for appellate review of the issue on appeal. The following further development is required. As a preliminary matter, an October 2007 VA treatment record indicates that the Veteran filed for Social Security Disability Insurance (SSDI) from the Social Security Administration (SSA) because of his mental condition, but there is no record of the outcome of the Veteran's claim. Therefore, it is possible that the Veteran is in receipt of SSA benefits. When VA is put on notice of the existence of SSA records, as here, VA must seek to obtain those records before proceeding with the appeal. Lind v. Principi, 3 Vet. App. 493, 494 (1992); Masors v. Derwinski, 2 Vet. App. 181, 188 (1992) (VA has a duty to acquire both the SSA decision and the supporting medical records pertinent to a claim); Murincsak v. Derwinski, 2 Vet. App. 363 (1992) (medical records upon which an award of SSA disability benefits have been predicated are relevant to VA claims for service connection and an increased rating). As such, all relevant SSA records need to be obtained and associated with the claims file. With regard to the Veteran's hypertension claim, in May 2009, he asserted that his hypertension was caused by his fibromyalgia medication. In May 2005, a VA treatment record noted that the Veteran had been diagnosed with hypertension three months prior, and his "[e]levated blood pressure could be related to his Adderall prescription." In November 2007, a VA health care provider noted that the Veteran "ask[ed] that I document his hypertension due to a service-connected myofascial pain syndrome. Because I am not managing his fibromyalgia, I will defer this to his chronic pain provider for comment." The Veteran's chronic pain provider did not comment on a possible connection between fibromyalgia and hypertension. In this case, a VA examination is warranted. In McLendon v. Nicholson, 20 Vet. App. 79 (2006), the Court made clear that VA must provide a VA medical examination when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran's service or with another service-connected disability, but (4) insufficient competent medical evidence on file for VA to make a decision on the claim. The Veteran has been diagnosed with hypertension. A VA health care provider suggested that it may have been caused by one of his prescription medications, which provides an indication that his hypertension may be related to his service-connected fibromyalgia or another service-connected condition. However, there is not enough medical evidence of record for the Board to adjudicate his claim. On remand, the Veteran should be scheduled for a VA examination to determine the etiology of his hypertension. With regard to his skin condition, in his June 2009 Substantive Appeal, the Veteran's representative argued that the Veteran was exposed to plutonium, uranium, tritium, and depleted uranium in service because he worked with nuclear munitions, and at one point worked at a nuclear test site. The Board notes that there is no indication in the claims file that all necessary development of the Veteran's claims pursuant to 38 C.F.R. § 3.111 has been undertaken. For example, it does not appear that the Veteran's claim for service connection for a skin condition have been properly developed pursuant to the provisions of 38 C.F.R. § 3.311(a)(2)(iii). Therefore, any such necessary development should be undertaken on remand. Further, the Board finds that an examination is warranted for the Veteran's skin condition. The Veteran has been diagnosed with several skin conditions, including folliculitis, atopic dermatitis, papular acne, cysts, and tinea pedis. His STRs show that he was treated for skin conditions several times in service. One of his STRs notes that he was exposed to black lacquer and enamel thinner as part of his duties. A May 2007 VA treatment report noted that the Veteran had some cysts on his arms and trunk "from when he was in the Persian Gulf." The physician's statement meets the very low threshold requirement for an indication that the condition may be related to service. McLendon, 20 Vet. App. at 79. There is also conflicting medical evidence that needs to be resolved by a VA examination and etiology opinion. A December 2008 VA treatment record notes that the Veteran had "extensive chronic accumulative sun damage related to living in Vegas in the past." This should be discussed by the examiner. Lastly, on examination, the physician will be asked to address the Veteran's contentions that his skin condition was caused by exposure to chemicals during service and radiation during service. With regard to the Veteran's claim for an acquired psychiatric disorder, the Veteran has been diagnosed with multiple mental disorders, including PTSD, major depressive disorder, and attention deficit hyperactivity disorder (ADHD). He has also claimed service connection for an unspecified "nerve condition," including as due to exposure to chemicals and radiation. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). Therefore, the Board must remand the issue of entitlement to a psychiatric disorder for development and adjudication. As noted above, the Veteran's claims for disabilities, including an unspecified nerve condition, which he asserts was caused by radiation exposure have not been developed pursuant to the provisions of 38 C.F.R. § 3.311(a)(2)(iii). Further, VA treatment records indicate that the Veteran received treatment for PTSD from two specific doctors at the Watertown VA Outpatient Clinic (VAOPC). These records have not been obtained and associated with his claims file. Records generated by VA facilities that may have an impact on the adjudication of a claim are considered constructively in the possession of VA adjudicators during the consideration of a claim, regardless of whether those records are physically on file. See Dunn v. West, 11 Vet. App. 462 (1998); Bell v. Derwinski, 2 Vet. App. 611 (1992). VA has a duty to seek such records. 38 C.F.R. § 3.159(c) (2010). On remand, the RO must obtain the Veteran's treatment records from the Watertown VAOPC. Moreover, during the course of the appeal, VA amended its adjudication regulations governing service connection for PTSD by liberalizing, in certain circumstances, the evidentiary standard for establishing the required in-service stressor, effective July 13, 2010. Specifically, the final rule amends 38 C.F.R. § 3.304(f) by redesignating current paragraphs (f)(3) and (f)(4) as paragraphs (f)(4) and (f)(5), respectively, and by adding a new paragraph (f)(3) that reads as follows: (f)(3) If a stressor claimed by a Veteran is related to the Veteran's fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of [PTSD] and that the Veteran's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the Veteran's service, the Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. For purposes of this paragraph, "fear of hostile military or terrorist activity" means that a Veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the Veteran or others, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the Veteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. Compare 38 C.F.R. § 3.304(f) (2010) with 75 Fed. Reg. 39843 -52 (July 13, 2010). The Veteran has not been notified of the regulatory amendment. Therefore, the RO should take this opportunity to provide him with the amended version of 38 C.F.R. § 3.304(f). The Veteran has claimed that his current PTSD is related to three reported in-service stressors. First, that he was shot at and had rocks thrown at him while driving in Riyadh, Saudi Arabia. Second, that he saw many dead bodies while serving in Kuwait. Third, that while working in an ammunition dump, his unit was attacked by rockets, which flew over the dump in close proximity to him. He specifically reported that he feared terrorist attacks while serving in the Persian Gulf. The RO has indicated that the Veteran's reported in-service stressors could not be verified without more information provided by him. However, in light of the amended regulation and the evidence of a current disorder, the Board finds that a VA examination and medical opinion are necessary for the purpose of determining the nature and etiology of any psychiatric disorders that may be present. Accordingly, the case is REMANDED for the following action: 1. The RO should contact the Veteran and determine whether he is in receipt of SSA benefits. If he responds in the affirmative, the RO should obtain a copy of the decision to grant SSA benefits to the Veteran and the records upon which that decision was based and associate them with the claims file. If the search for the records is unsuccessful, and further attempts to obtain them would be futile, the RO should document this in the claims file and notify the Veteran in accordance with 38 C.F.R. § 3.159(c)(2) and (3). 2. The Veteran should be afforded a VA examination to determine the nature and etiology of any hypertension that may be present. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, his post-service medical records, and the assertions made by the Veteran and his representative. It should be noted that the Veteran has claimed that his hypertension is the result of his medications for his service-connected fibromyalgia. The examiner should opine as to whether it is at least as likely as not that the Veteran's hypertension was caused by or permanently aggravated by his service-connected fibromyalgia or is otherwise directly related to his military service. In so doing, the examiner should discuss whether any of the Veteran's medications may have caused or aggravated his hypertension. If the examiner finds that a medication has caused or aggravated hypertension, he or she should state the name of the medication and the condition it is prescribed to treat. In determining whether aggravation has occurred, the examiner must state whether there has been an increase in the severity of his hypertension, and, if so, whether that increase is proximately due to or the result of the service-connected fibromyalgia rather than due to the natural progress of the disorder. (The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of conclusion as it is to find against it.) A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Since it is important "that each disability be viewed in relation to its history[,]" 38 C.F.R. § 4.1 (2010), copies of all pertinent records in the appellant's claims file, or in the alternative, the claims file, must be made available to the examiner for review. 3. The RO should develop the Veteran claims for a skin condition and an acquired psychiatric disorder as necessary in accordance with the provisions of 38 C.F.R. § 3.311, to specifically include 38 C.F.R. § 3.311(a)(2)(iii). The RO should determine whether the Veteran was exposed to radiation, and if so, should obtain a dose estimate. The RO should document all actions that are taken and any determinations that are made. 4. The Veteran should be afforded a VA examination to determine the nature and etiology of any skin conditions that may be present. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, his post-service medical records, and the assertions made by the Veteran and his representative. It should be noted that the Veteran has claimed that his skin condition is the result of exposure to black lacquer and enamel thinner, or in the alternative, to exposure to radiation from plutonium, uranium, tritium, and depleted uranium in service. The examiner should discuss that the Veteran received treatment for skin problems several times during service. He was treated for tinea pedis in October 1989, and placed on profile for this condition in May 1991. In August 1991 he was noted to have sebaceous cysts on his arm and neck, and he was prescribed medication for this condition. Also in August 1991, he had folliculitis of his pubic hair. In January 1992, he was treated for papules on his face, forehead, and jaw, and was diagnosed with papular acne. In March 1992 and January 1993, he was treated for bumps on his penis. Also in January 1993, he reported recurrent cystic lesions on his face and trunk. The examiner should comment on the December 2008 VA treatment record which described extensive post-service sun exposure from living in Las Vegas. The examiner should identify all current skin conditions. For each condition specified, the examiner should state whether it is at least as likely as not the disorder is causally or etiologically related to the Veteran's military service, including exposure to black lacquer and enamel thinner or exposure to radiation. (The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of conclusion as it is to find against it.) A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Since it is important "that each disability be viewed in relation to its history[,]" 38 C.F.R. § 4.1 (2010), copies of all pertinent records in the appellant's claims file, or in the alternative, the claims file, must be made available to the examiner for review. 5. The RO should obtain the Veteran's treatment records from the Watertown VAOPC, including his mental health treatment records from the two doctors identified by him. 6. The RO should develop the Veteran's claim for service connection for a psychiatric disorder, including all necessary notification and assistance. After completing all appropriate development, the RO should adjudicate the claim in accordance with Clemons v. Shinseki, 23 Vet. App 1 (2009). 7. The Veteran should be afforded a VA examination to determine the nature and etiology of any and all psychiatric disorders that may be present. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed, but should include psychological testing, including PTSD sub scales. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and assertions. The examiner should identify all current psychiatric disorders. The examiner should also indicate whether any psychosis had its onset within one year of the Veteran's discharge from active duty on September 11, 1993. For each disorder identified other than PTSD, the examiner should state whether it is at least as likely as not the disorder is causally or etiologically related to the Veteran's military service, including exposure to black lacquer and enamel thinner or exposure to radiation. The examiner should comment on the Veteran's in-service treatment for mental conditions. In March 1990 he was referred to a social actions program after two minor disciplinary actions. In April 1990, he was receiving therapy. He completed the social actions program with no diagnosis. In August 1992, he began individual therapy after an allegation of possible spousal abuse. In August 1992, September 1992, and October 1992, he was receiving marital and individual therapy. (The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of conclusion as it is to find against it.) With respect to PTSD, the RO should provide the examiner with a summary of any verified in-service stressors, and the examiner must be instructed that only these events and any stressors related to fear of hostile military or terrorist activity may be considered for the purpose of determining whether exposure to an in-service stressor has resulted in PTSD. If there is a verified stressor or there is a stressor related to fear of hostile military or terrorist activity consistent with his service, the examiner should determine whether the diagnostic criteria to support the diagnosis of PTSD have been satisfied. If the PTSD diagnosis is deemed appropriate, the examiner should then comment upon the link between the current symptomatology and any verified in-service stressor, including the fear of hostile military or terrorist activity. The examiner should specifically comment on the Veteran's reported stressors of being shot at and having rocks thrown at his vehicle in Riyadh, seeing dead bodies in Kuwait, and being present for a rocket attack on the ammunition dump where he was working. It should be noted that he reported fearing terrorist attacks while serving in the Persian Gulf. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Since it is important "that each disability be viewed in relation to its history[,]" 38 C.F.R. § 4.1 (2010), copies of all pertinent records in the appellant's claims file, or in the alternative, the claims file, must be made available to the examiner for review. 8. After completing the above actions, the RO should conduct any other development as may be indicated as a consequence of the actions taken in the preceding paragraphs. 9. Thereafter, and after undertaking any additional development deemed necessary, readjudicate the issues on appeal. If the benefits sought on appeal remain denied, in whole or in part, the Veteran and his representative should be provided with a Supplemental Statement of the Case and be afforded reasonable opportunity to respond. The case should then be returned to the Board for further appellate review, if otherwise in order. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2010). ______________________________________________ N. Rippel Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs