Citation Nr: 1234972 Decision Date: 10/09/12 Archive Date: 10/17/12 DOCKET NO. 07-38 302 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for a left knee disability. 2. Entitlement to service connection for bilateral hearing loss. 3. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), depression, anxiety, and dementia. REPRESENTATION Appellant represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD C. C. Dale, Counsel INTRODUCTION The Veteran had active duty service from August 1951 to May 1954. This matter comes before the Board of Veteran Appeals' (Board) on appeal from September 2007 and April 2009 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio, and Waco, Texas, respectively, which denied the above-noted issues. The Veteran timely appealed these issues. Jurisdiction is with the RO in Waco, Texas. The Veteran testified at a personal hearing before a Decision Review Officer (DRO) in October 2008. A transcript of that hearing is associated with the claims file. The Veteran initially requested a hearing in his November 2009 substantive appeal. He withdrew his hearing request later in the same month. 38 C.F.R. § 20.702(e). The Board remanded the claims on appeal in March 2010 and April 2011. Unfortunately, with regard to the claimed left knee disability, additional development remains necessary. A review of the Veteran's Virtual VA paperless claims processing system efolder does not reveal any pertinent documents that are not already associated with the claims folder. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2011). 38 U.S.C.A. § 7107(a)(2) (West 2002). The issue of service connection for a left knee disability is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran was exposed to acoustic trauma during service, and he is presently diagnosed with a hearing loss disability for VA purposes; however, the weight of the competent evidence is against a finding that his current hearing loss is related to in-service acoustic trauma. 2. The most competent and probative evidence establishes that the Veteran does not meet the criteria for a current PTSD diagnosis at any time during the claims period. 3. The weight of the competent evidence demonstrates that additional current psychiatric diagnoses of record are not related to or caused by any event or circumstance of the Veteran's active duty service. CONCLUSIONS OF LAW 1. The criteria for service connection for hearing loss in either ear have not been met. 38 U.S.C.A. §§ 1101, 1110, 1131, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.385, 4.85 (2011). 2. The criteria for service connection for a psychiatric disorder, to include PTSD, have not been met. 38 U.S.C.A. §§ 1101, 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2011); 75 Fed. Reg. 39843 (Jul. 13, 2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS 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. 2011); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2011). Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In addition, the notice requirements of the VCAA apply to all elements of a service-connection claim, including the degree of disability and the effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. VCAA notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). Here, the Veteran was sent letters in October 2006 and February 2008 that provided information as to what evidence was required to substantiate the claims and of the division of responsibilities between VA and a claimant in developing an appeal. It also explained what type of information and evidence was needed to establish a disability rating and effective date. Next, VA has a duty to assist the Veteran in the development of the claims. This duty includes assisting him in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). The claims file contains some personnel records, a May 1954 separation examination report, and post service VA treatment records. The Veteran was afforded an adequate VA psychiatric examination in October 2011. He also underwent adequate audiological evaluations in October 2008 and October 2011 with an accompanying November 2011 addendum report. Barr v. Nicholson, 21 Vet. App. 303 (2007). The Veteran's service treatment records, with the exception of the separation examination report, are not associated with the claims folder. The agency of original jurisdiction (AOJ) contacted the National Personnel Records Center (NPRC) in an attempt to locate these records. In November 2006, the NPRC stated that the service treatment records were destroyed in a fire and could not be reconstructed. The same month the AOJ informed the Veteran that service records continued to be unavailable. It also informed him that VA records currently on file were limited to those from 1985 to 1987 and January 2006 through the present. He was instructed to submit additional information or evidence. The AOJ sent the Veteran a February 2009 PTSD questionnaire to further assist him in developing his claim. The Veteran has not identified any instance of medical treatment for psychiatric or hearing problems during active service. See October 2006 Veteran statement. Additionally, in March 2008, the NPRC indicated that the Veteran's service personnel records were also unavailable as they had been destroyed in a fire. The Veteran reported receiving VA treatment at Dallas and Fort Worth, Texas, in the 1960s. The AOJ contacted the appropriate medical center (VAMC) for these records, and they provided negative responses in December 2008 and February 2009. The Veteran was specifically informed that these records were unavailable in May 2009. The Board recognizes that it has a heightened obligation to assist the Veteran in the development of his case, and to explain findings and conclusions, as well as carefully consider the benefit-of-the-doubt rule when records in the possession of the government are presumed to have been lost or destroyed. See O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). The case law does not, however, lower the legal standard for proving a claim for service connection, but rather increases the Board's obligation to evaluate and discuss in its decision all of the evidence that may be favorable to the Veteran. Russo v. Brown, 9 Vet. App. 46 (1996). The Board finds that, based on the AOJ's efforts and the responses from the service department and VAMCs, it is reasonably certain that the Veteran's service treatment records and reported VA treatment records from the 1960s are unavailable and that further efforts to obtain them would be futile. 38 U.S.C.A. § 5103A(b)(3)); see also Hayre v. West, 188 F.3d 1327 (Fed. Cir. 1999); O'Hare, 1 Vet. App. at 367. The March 2010 Board remand requested that the AOJ verify the Veteran's period of service. To this end, the Veteran's DD 214 has been located. The April 2011 Board remand included instructions to request VA treatment records beginning April 2009, submit another request for service treatment records and Army hospital records, and provide a VA psychiatric examination. The addition of updated VA treatment records and October 2011 VA psychiatric examination report reflects substantial compliance. Although the RO did not resubmit a request for service treatment records, the November 2006 NPRC response is clear that the service treatment records were destroyed in a fire and are not available. As stated above, additional requests would be futile. The April 2011 remand also instructed the AOJ to search for unit action and morning reports for the Veteran's units. The AOJ made a request through the Defense Personnel Records Information Retrieval System (DPRIS). DPRIS results were only able to confirm that there were no fatalities for the Veteran's unit from March 1st to May 31st, 1952 and suggested that the AOJ provide additional search requests in 60 day time frames. The AOJ has not done so. However, the October 2011 VA psychiatric examination report shows that the Veteran does not have a diagnosis of PTSD. In addition, his reported stressors involving hostile military activity have been conceded. His current diagnosis is anxiety, which is not shown to be related to active service. Although additional efforts to verify stressors have not been conducted, the October 2011 VA examination report findings obviate the need to do so. As explained below, the Board finds that the probative evidence does not show that the Veteran has a current PTSD diagnosis. Since the probative evidence does not establish a current PTSD diagnosis and his reported stressors involving fear of hostile military activity have been conceded, a remand for further development to verify underlying stressors that do not involve fear of hostile military activity would not be of additional assistance in developing the claim. 38 C.F.R. § 3.159. For the reasons stated above, the Board considers the record to be in substantial compliance with the March 2010 and April 2011 Board remands for the issue decided herein. A remand by the Board confers upon the claimant, as a matter of law, the right to compliance with the remand order. Stegall v. West, 11 Vet. App. 268 (1998). Nonetheless, it is only substantial compliance, rather than strict compliance, with the terms of a remand that is required. See D'Aries v. Peake, 22 Vet. App. 97, 104-05 (2008) (finding substantial compliance where an opinion was provided by a neurologist as opposed to an internal medicine specialist requested by the Board); Dyment v. West, 13 Vet. App. 141 (1999). The Board notes the Veteran had an October 2008 RO/AOJ hearing. Notably, the issue of service connection for a psychiatric disability was not on appeal at that time. The Court has held that the provisions of 38 C.F.R. § 3.103(c)(2) (2011) impose two distinct duties on VA employees, including Board personnel, in conducting hearings: The duty to explain fully the issues and the duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010) (per curiam); See also 77 Fed. Reg. 23128-01 (April 18, 2012). At the October 2008 hearing, the Decision Review Officer (DRO) identified the issue of service connection for bilateral hearing loss, which was on appeal at that time. The Veteran provided testimony as to his history of noise exposure and the nature of his hearing loss disability. He did not identify any outstanding audiological medical records. The duties imposed by Bryant were thereby met. For the above reasons, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the Veteran in the development of the claims. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). II. Service connection for an acquired psychiatric disorder Laws and regulations Service connection may be granted 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(a). Service connection generally requires credible and competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Hickson v. West, 12 Vet .App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498 (1995). The second and third requirements may be satisfied with evidence of a chronic disease shown during service or a continuity of symptomatology. See 38 C.F.R. § 3.303(b); see Savage v. Gober, 10 Vet. App. 488, 495-96 (1997). For the sake of clarity, the Board initially notes that the scope of the claim most reasonably encompasses a claim of service connection for any psychiatric disorder, to include PTSD, but also including anxiety, depression, and dementia. See Clemons v. Shinseki, 23 Vet. App. 1 (2009); Brokowski v. Shinseki, 23 Vet. App. 79, 86-88 (2009). Establishing service connection for PTSD requires (1) medical evidence diagnosing PTSD in conformance with the DSM-IV criteria; (2) a link, established by medical evidence, between a Veteran's present symptoms and an in-service stressor; and (3) credible supporting evidence that the claimed in-service stressor actually occurred. See 38 C.F.R. § 3.304(f); Cohen v. Brown, 10 Vet. App. 128, 139 (1997). If PTSD was diagnosed by a medical professional, VA must assume that the diagnosis meets the DSM-IV criteria relating to adequacy of the symptomatology and sufficiency of the stressor. See Cohen, 10 Vet. App. at 153. If a Veteran's claimed stressor relates to an event in which he engaged in combat with the enemy, his lay testimony, alone, is sufficient to verify the claimed in-service stressor. VAOPGCPREC 12-99, p. 4 (October 18, 1999); Gaines v. West, 11 Vet. App. 353 (1998). Establishing that the Veteran engaged in combat with the enemy requires objective, competent, and factual evidence of record. See id. The determination is made on a case-by-case basis and means that the Veteran personally participated in events constituting an actual fight or encounter with a military foe or hostile unit or instrumentality. VAOPGCPREC 12-99 (Oct. 18, 1999); see also Sizemore v. Principi, 18 Vet. App. 264, 273-74 (2004). Furthermore, effective July 13, 2010, if a stressor claimed by a Veteran is related to that 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 a 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 that Veteran's service, a Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304(f)(3). "[F]ear 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. See id. The occurrence of an actual event or circumstance is necessary. In making this determination, VA must duly consider the places, types, and circumstances of a Veteran's service as shown by the service record, the official history of each organization in which such a Veteran served, a Veteran's medical records, and all pertinent medical and lay evidence. The new rule is limited to cases in which the claimed stressor is related to a Veteran's fear of hostile military or terrorist activity. See id. Otherwise, when the claimed stressor is not related to combat, a Veteran's lay statements alone are not sufficient to establish the occurrence of the alleged stressor. Moreau v. Brown, 9 Vet. App. 389, 395-396 (1996); Dizoglio v. Brown, 9 Vet. App. 163, 166 (1996). Rather, the record must contain service records or other corroborative evidence substantiating the Veteran's testimony or statements as to the occurrence of the claimed stressors. See West (Carlton) v. Brown, 7 Vet. App. 70, 76 (1994); Zarycki v. Brown, 6 Vet. App. 91, 98 (1993). The Board need not accept a non-combat Veteran's lay statements asserting that an event (as opposed to medical symptoms) actually occurred, even though there is no "affirmative documentary evidence provid[ing] otherwise." Rather, all the evidence of record, including the absence of documentation in the military records, must be weighed in determining whether an event actually occurred. Bardwell v. Shinseki, 24 Vet. App. 36, 40 (2010); compare Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006) (finding that it was impermissible for the Board to find a Veteran's lay statements regarding his medical symptoms not credible merely because there was no "confirmatory medical evidence"). The Board's duty is to assess the credibility and competency of all material evidence to determine its probative weight. See Dalton v. Nicholson, 21 Vet. App. 23, 36 (2007); Wood v. Derwinski, 1 Vet. App. 190, 193 (1991); see also Layno v. Brown, 6 Vet. App. 465, 469 (1994) (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). In making all determinations, the Board must also fully consider the lay assertions of record. If credible, 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(a). Thus, a layperson is competent to report on the onset and continuity of his symptomatology. See Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011); Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis if (1) the medical issue is within the competence of a layperson, (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. See Kahana, 24 Vet. App. at 433; Davidson, 581 F.3d at 1316; Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). For instance, a lay person may speak to etiology in those limited circumstances where a nexus is obvious merely through observation, such as a fall leading to a broken leg. Jandreau, 492 F.3d 1372, 1376-77. Factual Background As noted above, limited service records are available. Thus, the Board has a heightened duty to explain its findings and consider the benefit of the doubt doctrine. O'Hare, 1 Vet. App. at 367; Russo, 9 Vet. App. 46. However, the legal standard for establishing service connection remains the same. Id. The available service records confirm that the Veteran had active service from August 1951 to May 1954, including approximately two years of foreign service in Germany. At one time the Veteran reported being on active duty from 1947 to 1958. However, such reports are inconsistent with the available service records showing civilian employment from 1948 to 1951. See DD 214. At the outset, the record shows that the Veteran served near the German border in the early 1950s. The Board takes judicial notice that there have been multiple incidents of cross-border incursions, shootings, and kidnapping. See http://www.history.army.mil/documents/BorderOps/ch3.htm#p51 (last visited October 3, 2012). Consequently, any stressor regarding fear of hostile military while stationed in Germany is conceded as consistent with the Veteran's service without the need for further verification. See 75 Fed. Reg. 39843 (Jul. 13, 2010). Throughout the course of the appeal, the Veteran has reported various in-service stressors. In November 2007, VA primary care (PCP) records show an assessment of depression and PTSD based upon the Veteran's self reported crying spells and nightmares about the Korean War. She referred him to the VA Mental Health Clinic (MHC). He visited the VA MHC in December 2007. He characterized his symptoms as depression and PTSD that flare-up on occasion. He reported a prior psychiatric hospitalization in 1963. He further detailed his service, stating that he joined the Army in 1948. He served in Korea on the Russian border as a bodyguard. He also drove a tank and was involved in combat. Upon mental status examination, he had an appropriate appearance and normal speech. However, he his mood was irritable. He denied homicidal ideation, but affirmed passive suicidal ideations. The examiner diagnosed PTSD and major depressive disorder, recurrent, mild. She cited his reported Korean War stressors. At the October 2008 DRO hearing, the Veteran alluded to crying spells and nervous problems immediately after service. He offered these reports in the context of his hearing loss claim. The Veteran submitted a February 2009 stressor statement. He reported that he had PTSD due to incidents that occurred in Korea. In May 2009, he provided three first names of soldiers he knew that were killed in action due to artillery battlefield crossfire. He listed the deaths as occurring in Erlangen, Germany between 1948 and 1951. In his November 2009 substantive appeal, the Veteran stated that he could not remember the last names of the soldiers killed. He reported that the death of these men was tragic and that he had trouble sleeping due to the incident. A VA psychiatric examination was afforded in October 2011. The examiner concluded that the Veteran did not meet the criteria for a PTSD diagnosis. Instead, he met the criteria for Anxiety disorder and rule out dementia. He characterized the overall severity of the Veteran's occupational and social impairment as due to mild or transient symptoms. The examiner reviewed the claims folder and noted the Veteran's social and occupational history. Pertinently, the Veteran reported seeking mental health treatment on one occasion, but declining further treatment based upon the clinician's assertion that his problems were due to his children. He denied having problems with depression or non-PTSD anxiety or any family mental health history. The Veteran reported several stressors at the October 2011 VA examination. First, he reported that witnessing two of his friends being fatally injured when they dropped their weapons. Then, he reported falling off of a tank and breaking his knee. He also reported riding on a tank and pushing one of three German soldiers off and thereby killing him. The examiner commented that the reports of falling off the tank would not meet the PTSD stressor criterion A. He noted that the Veteran did not recall the incident of witnessing three soldiers being killed during artillery crossfire that he reported in February 2009. Upon questioning, the Veteran provided a vague response referencing artillery fire and friends being run over by vehicles. The examiner noted that such stressors appear to relate to hostile enemy activity, but the Veteran was unable to provide further details about incident. The examiner detailed each PTSD criterion and how the Veteran's reports related to it. He determined that the Veteran had provided reports of traumatic events for (criterion A). He had persistent dream of the traumatic memory meeting the threshold for criterion B. However, for criteria C (persistent avoidance) and D (persistent increased arousal), the Veteran did not report sufficient symptoms to meet these criteria. Thereby, the examiner concluded that he did not meet the criteria for a PTSD diagnosis. He noted that the Veteran had the following psychiatric symptoms: anxiety, sleep disturbance, impaired memory, speech impairment, difficulty understanding complex commands, and suicidal ideation. The examiner observed that the Veteran had negative depression screens in September 2001 and November 2011. He also had negative PTSD screens in June 2005, June 2006, and November 2007. He recounted the Veteran's narrative of his PTSD stressors. He concluded that the Veteran did not meet the PTSD criteria. He noted the Veteran was a very poor historian as to the details of his stressors. He stated that he attempted to lead him with questioning about the stressors to little avail. He commented that the Veteran appeared to have mild dementia and his memory for historical events was poor. Moreover, while the Veteran had reported sufficient criteria for a PTSD diagnosis in December 2007, this was based upon reports of service in Korea which had not been shown, as opposed to Germany, which had been verified. He concluded that overall there is insufficient evidence to support a PTSD diagnosis, and it is less likely related to service. The examiner further noted that the Veteran had some psychological distress from military experiences. He currently reported distress sufficient to support an Anxiety diagnosis. However, the etiology of the anxiety was unclear. He commented that it may be residual anxiety from what once was PTSD in the past, but such a possibility was speculative. He again stated that etiology of the anxiety was unclear and noted that these problems were not reported until over forty years after separation. For these reasons, he concluded anxiety was less likely related to service. He also noted the Veteran had mild dementia and recommended neuropsychological evaluation. He reported the onset of cognitive and psychiatric problems is unclear, and it would speculative to attribute his dementia as the primary cause of his anxiety. Analysis The Veteran contends that service connection for an acquired psychiatric disability, to include PTSD, is warranted. However, as explained below, the preponderance of the evidence is against the claim, and it will be denied. (i) PTSD The Veteran asserts that he has PTSD. In this regard, he is competent to describe his psychiatric symptoms. Layno, 6 Vet. App. at 470. As an initial matter, the Board notes that the question of whether he has a clinical PTSD diagnosis is a complex medical question beyond the capabilities of lay observation, and the Veteran is not shown to be a medical professional. Thus, his assertions that he has a clinical PTSD diagnosis are not competent evidence addressing the medical question of whether a clinical PTSD diagnosis is present. See Davidson, 581 F.3d at 1316; Jandreau, 492 F.3d at 1376-77. Accordingly, any contention of a clinical PTSD diagnosis by the Veteran has no probative value. Id. As noted above, in this case the record contains conflicting medical opinions on whether the Veteran has a valid PTSD diagnosis. When evaluating these medical opinions, the Board must analyze their credibility and probative value, account for evidence which it finds to be persuasive or unpersuasive, and provide reasons for rejecting any evidence favorable to the Veteran. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). In evaluating medical opinions, the Board may place greater weight on one medical professional's opinion over another's depending on such factors such as reasoning employed by the medical professionals, and whether or not and to what extent they review prior clinical records and other evidence. Gabrielson v. Brown, 7 Vet. App. 336 (1994). The competent medical evidence establishing a PTSD diagnosis are the November and December 2007 VA PCP and MHC treatment records. At that time, the Veteran reported stressors from the Korean War. The clinicians acknowledged the Veteran's reported stressor from the Korean War and current symptoms of depression and crying spells. They did not explain how the Veteran met each DSM-IV criterion necessary to establish a PTSD diagnosis or otherwise detailed their reasoning for listing a PTSD diagnosis. This omission weighs against the probative value of these records in showing a current PTSD diagnosis. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (the probative value of a medical opinion comes from when it is the factually accurate, fully articulated, and sound reasoning for the conclusion). In addition, the November and December 2007 VA treatment records are also premised on reports of Korean War stressors. The DD 214s confirm approximately two years of foreign service in Germany. The available service records do not in any way suggest that the Veteran served in Korea. The October 2011 VA examiner assessed the Veteran as a poor historian, which again weighs against the Veteran's reports of Korean service. See October 2011 VA psychiatric examination report. Overall, the Board finds the Veteran's reports of Korean service to be inconsistent with the evidence of record and to have no probative value. Caluza, 7 Vet. App. 498. The inaccurate factual premise underlying the VA PCP and MHC clinicians further undermines their reports. Barr, 21 Vet. App. 303; Gabrielson, 7 Vet. App. 336. By contrast, the October 2011 VA examiner carefully considered each reported stressor and queried the Veteran to assist him in elaborating his stressors. However, the examiner concluded that the Veteran was a poor historian and could only provide vague details. The examiner carefully assessed the Veteran's symptoms in light of each criterion that constitutes a PTSD diagnosis. He explained that the Veteran reported insufficient symptoms to meet criterions C and D, and consequently, a PTSD diagnosis was not warranted. In summary, the October 2011 VA examiner thoroughly reviewed the record and interviewed the Veteran. He provided a detailed analysis to support his negative determination. The Board considers the October 2011 VA medical opinion to be highly probative in showing that a current PTSD diagnosis is not warranted. See Nieves-Rodriguez, 22 Vet. App. 295 (2008). Moreover, the VA examiner's opinion is support by VA treatment records from 2001 showing multiple instances where the Veteran had negative psychiatric screens. The Board notes that the examiner commented that it was less likely than not that the Veteran has PTSD related to service, which would imply a current PTSD diagnosis. However, viewing his report in its entirely, it is clear to the reader that a PTSD diagnosis was not found. Caluza, 7 Vet. App. 498. In weighing the respective medical opinions, the Board concludes that the October 2011 VA examiner's opinion merits the greater probative weight. The opinion reflects familiarity with the Veteran's history and is accompanied by rationale that is supported by citation to reports made throughout the record and explanation of the significance of the Veteran's symptoms in the context of the DSM-IV PTSD diagnostic criteria. See Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007); Nieves-Rodriguez, 22 Vet. App. 295. The Board has considered that many of the Veteran's service records are missing as well as VA treatment records from the 1960s. O'Hare, 1 Vet. App. at 367; Russo, 9 Vet. App. 46 (1996). However, the reason for the current denial is lack of a current PTSD diagnosis and the association of these missing records would not affect this determination. Hence, the weight of the probative evidence is against a finding that the Veteran currently has PTSD. Accordingly, service connection for PTSD is denied. See id.; 38 U.S.C.A. § 5107(a); 38 C.F.R. §§ 3.102, 3.303, 3.304(f). (ii) Additional psychiatric disorders As previously noted, the Veteran's claim for service connection for PTSD encompasses all psychiatric diagnoses raised by the record. Clemons, 23 Vet. App. 1. During the pendency of the appeal, diagnoses of depression, anxiety, and dementia have been raised. See VA treatment records from November and December 2008; October 2011 VA psychiatric examination report. Again, in its analysis, the Board has considered that many of the Veteran's service records are missing as well as VA treatment records from the 1960s. O'Hare, 1 Vet. App. at 367; Russo, 9 Vet. App. 46 (1996). However, the Veteran does not report having treatment for depressive or anxiety symptoms in service. At the October 2008 DRO hearing, he provided vague reports to crying spells and a nervous disorder interfering with civilian employment immediately after separation. He has also provided vague reports as to an instance of VA psychological treatment in 1963, but it is unclear as to the nature and duration of such treatment. See VA treatment records, dated December 2007. He did not report this prior instance of treatment to the October 2011 VA examiner. In any event, the Board has considered these missing records in its determination. Id. The November and December 2007 clinicians attributed a diagnosis of depression to the Veteran's reports of Korean War memories. As noted above, the Veteran's DD 214 does not show that he served in Korea, and the October 2011 VA examiner assessed the Veteran as a poor historian. The inaccurate factual premise underlying the clinicians' assessments, again, greatly limits the probative value of their opinions. Barr, 21 Vet. App. 303; Gabrielson, 7 Vet. App. 336. In sum, the Board considers the November and December 2007 VA treatment reports to have minimal probative value in showing depression is related to service. See id. The October 2011 VA examiner found the Veteran to meet the DSM-IV Axis I diagnostic criteria for anxiety and mild dementia. He stated that the etiology was unknown, but that it was less likely related to service. He cited the lengthy time period in between service and reports of anxiety symptoms. The negative determination was based upon a longitudal review of the record and clinical assessment. The rationale, albeit brief, is plausible and consistent with the record. The Board considers the October 2011 VA examiner's negative opinion for anxiety to be probative and weigh against the claim. Barr, 21 Vet. App. 303. The Board notes that the October 2011 examiner conjectured that the Veteran may have residual anxiety from past symptoms that were sufficient to meet the PTSD diagnostic criteria. However, reviewing the examiner's comments as whole, it is clear that he listing a hypothetical history. Indeed, he states that such a determination would be speculative. Medical opinions must be expressed in terms of scientific certainty to be probative. 38 C.F.R. § 3.102; Stegman v. Derwinski, 3 Vet. App. 228, 230 (1992); Obert v. Brown, 5 Vet. App. 30, 33 (1993). It has also been observed that statements from doctors which are inconclusive as to the origin of a disease cannot be employed as suggestive of a linkage between the current disorder and the claimed incident of military service. Warren v. Brown, 6 Vet. App. 4, 6 (1993); Sklar v. Brown, 5 Vet. App. 104, 145-6 (1993). Thus, such a statement cannot be construed as evidence of nexus to service for anxiety. Id. There is no evidence suggesting that dementia is in any way related to active service. Dementia was manifested approximately nearly 60 years following active service. Without any evidence suggesting a nexus to service, service connection for dementia is not warranted. 38 C.F.R. § 3.303. The Board notes that at the October 2008 DRO hearing, the Veteran referenced crying spells and a nervous disorder interfering with civilian employment immediately after separation. However, these reports are vague and inconsistent with negative depression screens shown September 2001 and July 2005 VA treatment records. The record reflects that the Veteran successfully held a civilian job as a welder for many years and retired due to non-psychiatric medical disability. See March 1987 Employer statement. The Board considers the October 2008 reports to be vague and inconsistent with the record. They are thus of minimal probative value. Caluza, 7 Vet. App. 498. In sum, the Board does not find that there is probative evidence to show a continuity of symptomatology for psychiatric symptoms beginning in service. 38 C.F.R. § 3.303(b). For the foregoing reasons, the preponderance of the evidence is against the Veteran's claim for an acquired psychiatric disorder, to include PTSD, depression, anxiety, and dementia. The benefit-of-the-doubt doctrine is therefore not applicable and the claim for service connection for an acquired psychiatric disorder must be denied. See 38 U.S.C.A. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. at 55-57. III. Service connection for bilateral hearing loss Service connection may be granted 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(a). Service connection generally requires credible and competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Hickson v. West, 12 Vet .App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498 (1995). Additionally, certain chronic diseases, including sensorineural hearing loss, may be presumed to have been incurred during service if manifested to a compensable degree within one year of separation from active service. 38 U.S.C.A. §§ 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. § 3.303(b). Service connection may also be granted for any disease diagnosed after discharge when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection for hearing loss may be granted where there is credible evidence of acoustic trauma due to significant noise exposure in service, post-service audiometric findings meeting the regulatory requirements for hearing loss disability for VA purposes, and a medically sound basis upon which to attribute the post-service findings to the injury in service (as opposed to intercurrent causes). Hensley v. Brown, 5 Vet. App. 155, 159 (1993). For the purposes of applying the laws administered by VA, the thresholds for normal hearing are between 0 and 20 decibels, and higher thresholds show some degree of hearing loss. Id. at 157. Impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz (Hz) is 40 decibels or greater, or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, 4000 Hz 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. In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis if (1) the layperson is competent to identify the medical condition, (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. Davidson, 581 F.3d at 1316 (Fed.Cir.2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). A lay person may speak to etiology in some limited circumstances in which nexus is obvious merely through observation, such as a fall leading to a broken leg. Jandreau, 492 F.3d 1372, 1376-77. The Board's duty is to assess the credibility and weight of the evidence. See Dalton v. Nicholson, 21 Vet. App. 23, 36 (2007); Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). As noted above, limited service records are available. The Board has a heightened duty to explain its findings and consider the benefit of the doubt doctrine. O'Hare, 1 Vet. App. at 367; Russo, 9 Vet. App. 46. However, the legal standard for establishing service connection remains the same. Id. The Veteran reports that he had significant acoustic trauma during service. Indeed, his DD 214 confirms that he was an artillery crewman and served on the German Border in the early 1950s. His contentions of noise exposure are deemed credible and are consistent with the circumstances of his service, as indicated in the available official service records. See 38 U.S.C.A. § 1154(a). Based on the above, the Board concludes that he was exposed to significant acoustic trauma during active service. The May 1954 separation examination report shows 15/15 whisper voice hearing in both ears. VA treatment records, dated in August 2000, reflect findings of bilateral hearing loss in the course of a neurology consultation for vertigo symptoms (no puretone audiometric testing is shown). Subsequent VA treatment records, from October 2005, confirm bilateral sensorineural hearing loss meeting the VA definition of hearing loss. 38 C.F.R. § 3.385. At that time, he underwent an audiometry examination in the context of vertigo complaints, laryngitis, and allergy problems. VA treatment records from January and October 2006 show that he continued to complain of hearing loss. At his October 2008 DRO hearing, the Veteran again stated that he had significant acoustic trauma as part of service in an artillery battalion. He also acknowledged having noise exposure from his civilian occupation in a machine shop. He contended that his current hearing difficulties were related to acoustic trauma sustained in active service. The Veteran underwent an October 2008 VA audiology examination. He was afforded a clinical examination in compliance with 38 C.F.R. § 4.85. It again confirmed VA recognized bilateral sensorineural hearing loss. The audiologist considered the Veteran's reports of noise exposure from in-service artillery fire and post service occupational noise exposure from working in a machine shop. He noted the normal whisper voice findings at separation and recent audiological treatment. Based upon a longitudal review of the record. He reported that the dominant etiology for hearing loss would be presbycusis. He concluded that it is less likely related to military noise exposure. VA reexamined the Veteran for hearing loss in October 2011. He again underwent a clinical examination in compliance with 38 C.F.R. § 4.85. It confirmed VA recognized bilateral sensorineural hearing loss. The VA audiologist declined to provide a rationale without reviewing the claims folder. In a November 2011 addendum, she stated that she reviewed the claims folder and provided a negative opinion. As her rationale she cited absence of findings of hearing loss at separation, forty years between the service and initial recorded observation of symptoms, and the long history of post-service occupational noise exposure. The evidence shows that the Veteran experienced in-service acoustic trauma and currently has a bilateral hearing loss disability as recognized by VA. 38 C.F.R. § 3.385. Accordingly, the remaining question for consideration is whether the current bilateral hearing loss disability is etiologically related to the in-service acoustic trauma. See Davidson, 581 F.3d at 1316. Although the Veteran cannot diagnose hearing loss for VA purposes, he is competent to report on hearing difficulties. Id. In the case at hand, the etiology of the currently diagnosed hearing loss is not readily apparent as many years have elapsed since the initial diagnosis of hearing loss recognized by VA and active service. Thus, the question of an etiology involves medical considerations beyond lay observation. Jandreau, 492 F.3d at 1376-77. The Veteran has not been shown to have medical expertise in audiology, and he is not competent to provide an audiological medical opinion. See id. Thus, while he may genuinely believe his hearing loss is related to in-service acoustic trauma, he is not qualified to report on the etiology of his hearing loss and his etiology opinion has no probative value. Id. The competent medical opinions weigh against the claim. Both VA audiologists considered the Veteran's history and opined that it is less likely his current hearing loss is etiologically related to service. Their opinions are plausible and consistent with the record, which includes reports of many years of post service noise exposure. Moreover, they are uncontroverted by the medical evidence of record. The Board considers both opinions to be probative medical evidence that weighs against the claim. See Dalton, 21 Vet. App. at 36. For the foregoing reasons, the preponderance of the evidence is against the Veteran's claim. The benefit-of-the-doubt doctrine is therefore not applicable and the claim for service connection for bilateral hearing loss must be denied. See 38 U.S.C.A. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. at 55-57. ORDER Service connection for bilateral hearing loss is denied. Service connection for an acquired psychiatric disorder, to include PTSD, depression, anxiety, and dementia is denied. REMAND With respect to the left knee claim, additional development is necessary. The April 2011 remand instructed the AOJ to continue searching for the Veteran's reports of left knee treatment at Erlangen and Nuremburg, Germany, Army Hospitals from January 1953 to April 1954 until it was concluded that further attempts would be futile. In searching for these hospital records, the AOJ submitted an August 2011 Personnel Information Exchange System (PIES) request for hospital records at Erlangen and Nuremburg, Germany from January 1953 to April 1954. In September 2011, the NPRC requested the Veteran's organization information. The AOJ submitted this information, but a response has not been provided. Accordingly, the Board finds that all efforts to locate service hospital records have not been exhausted. 38 C.F.R. § 3.159(c)(2). In addition, the Board finds the July 2010 VA left knee examination report to be inadequate. The July 2010 VA examiner implicitly rejected the Veteran's reports of injuring his left knee based upon an absence of contemporaneous medical treatment. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence"). A medical opinion based solely on the absence of documentation in the record is inadequate and a medical opinion is inadequate if it does not take into account the Veteran's reports of symptoms and history (even if recorded in the course of the examination). Dalton v. Peake, 21 Vet. App. 23 (2007). The AOJ must obtain another medical opinion as detailed in the instructions below. Ongoing private and VA treatment records should also be obtained. See 38 U.S.C.A. § 5103A(b), (c); 38 C.F.R. § 3.159(b); 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: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2011). Expedited handling is requested.) 1. Obtain any relevant VA treatment records for treatment since April 2011 and associate those documents with the claims file. 2. Ensure that a response is received to the September 2011 request in search of Erlangen and Nuremburg, Germany Army Hospitals records for the period from January 1953 to April 1954. All search efforts must be documented in the record. 3. After conducting the development above and associating all pertinent records with the claims folder, arrange for an appropriately qualified medical examiner to furnish a medical opinion regarding the etiology of the Veteran's current left knee disability. The claims folder (to include either paper copies of, or electronic access to, all Virtual VA documents that are not already a part of the physical claims folder) and a copy of this remand must be made available to the examiner. He or she should indicate receipt and review in any report generated. For the purpose of the opinion, the examiner must accept as fact that the Veteran injured his left knee during service and sought medical attention at that time. Following review of the entire record, the examiner is asked to identify all current left knee diagnosis(es). The examiner should then state whether any left knee disorder is at least as likely as not (50 percent or greater probability) related to the left knee injury reported during active military service or is otherwise related to active military service. The examiner must include a detailed medical rationale that reflects consideration of the Veteran's lay reports of his left knee injury after falling from a tank. Any medical opinions must be expressed in terms of scientific certainty. If the examiner cannot provide an opinion without resort to speculation, he or she must so state and further identify any outstanding evidence that would facilitate a non-speculative opinion. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. If the examiner rejects the Veteran's reports of symptomatology, the examiner must provide a reason for doing so and cannot reject the Veteran's reports based solely on an absence of contemporaneous medical treatment. 4. Following the above development, the RO/AMC should review the claims file and readjudicate the Veteran's claim for service connection for a left knee disability. If the benefits sought on appeal remain denied, the Veteran and his representative should be furnished a supplemental statement of the case and be given the opportunity to respond thereto before the case is returned to the Board. 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. 2011). ______________________________________________ ERIC S. LEBOFF Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs