Citation Nr: 1300907 Decision Date: 01/09/13 Archive Date: 01/16/13 DOCKET NO. 04-27 621 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Hartford, Connecticut THE ISSUES 1. Entitlement to service connection for macules on the tongue. 2. Entitlement to service connection for chronic bronchitis. 3. Entitlement to service connection for asthma. 4. Entitlement to service connection for chronic sinusitis. 5. Entitlement to service connection for a chronic heart disability manifested by a heart murmur. 6. Entitlement to service connection for hypertension. 7. Entitlement to service connection for right carpal tunnel syndrome. 8. Entitlement to service connection for left carpal tunnel syndrome. 9. Entitlement to service connection for bilateral pes planus. 10. Entitlement to service connection for a chronic low back disability. 11. Entitlement to service connection for status post salpingo-oophorectomy. 12. Entitlement to service connection for a psychiatric disability, to include posttraumatic stress disorder (PTSD) and a bipolar disorder. REPRESENTATION Appellant represented by: Connecticut Department of Veterans Affairs WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Biswajit Chatterjee, Counsel INTRODUCTION The Veteran served on active duty from January 1989 to July 2003. This appeal to the Board of Veterans' Appeals (Board) is from February 2004 and December 2005 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Hartford, Connecticut. The Veteran testified at a videoconference hearing at the RO in January 2008, before the undersigned Acting Veterans Law Judge of the Board. A transcript of the hearing is associated with the claims file. In July 2008 and again in October 2011, the Board remanded the case to the RO, via the Appeals Management Center (AMC), for additional development and consideration. In September 2012, the AMC issued a supplemental statement of the case (SSOC) continuing to deny the claims and returned the file to the Board for further appellate review. Unfortunately, still further development remains for the issues of entitlement to service connection for macules on the tongue, chronic bronchitis, chronic sinusitis, asthma, a chronic heart disability manifested by a heart murmur, bilateral pes planus, a chronic low back disability, and a psychiatric disability, including PTSD and bipolar 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. There is no competent and credible evidence that the Veteran has had left and right carpal tunnel syndrome or status-post salpingo-oophorectomy, since she filed her claim or during the pendency of the appeal. 2. Resolving any doubt in the Veteran's favor, hypertension was manifested during service. CONCLUSIONS OF LAW 1. Left and right carpal tunnel syndrome were not incurred in or aggravated by the Veteran's military service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.159, 3.303 (2012). 2. Status post salpingo-oophorectomy was not incurred in or aggravated by the Veteran's military service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.159, 3.303 (2012). 3. Resolving any doubt in the Veteran's favor, the Veteran's hypertension is presumed to have been incurred in service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107 (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VCAA As the Board's decision to grant the Veteran's claims of entitlement to service connection for hypertension is completely favorable, no further action is required to comply with the Veterans Claims Assistance Act of 2000 and the implementing regulations. Before addressing the merits of the remaining issues decided below (left and right carpal tunnel syndrome and status-post salpingo-oophorectomy), the Board notes that VA has a duty to notify and a duty to assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. §§ 3.159, 3.326(a). Proper notice from VA must inform the claimant and her representative, if any, prior to the initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ) of any information and any 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 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002). These notice requirements apply to all five elements of a service-connection claim (Veteran status, existence of a disability, a connection between the Veteran's service and the disability, degree of disability, and effective date of the disability). Dingess v. Nicholson, 19 Vet. App. 473 (2006). Information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded must be included. Id. Neither the Veteran nor her representative has alleged prejudice with respect to notice, as is required. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009); Goodwin v. Peake, 22 Vet. App. 128 (2008); Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). None is found by the Board. VA's duty to notify under 38 C.F.R. § 3.159(b)(1) has been met by letters from the RO issued in September 2003, February and May 2005, of the criteria for establishing direct service connection; the evidence required in this regard; and her and VA's respective duties for obtaining evidence. These letters accordingly addressed all notice elements and predated the respective, initial adjudications by the AOJ/RO in February 2004 and December 2005. The RO's notices were in the preferred sequence, without timing or content defects. Pelegrini v. Principi, 18 Vet. App. 112 (2004) (Pelegrini II). Subsequently, the RO sent additional notice letters compliant with § 3.159(b)(1) in June and December 2009. The RO also sent notices that complied with Dingess in March 2006 and December 2009. Since providing these notices, the AOJ has readjudicated the claims in the September 2012 SSOC - including considering the additional evidence received in response to this additional notice. So the timing defect in the provision of these additional notices, since they did not precede the initial adjudication of the claims, has been rectified ("cured"). The Veteran has not made any pleading or allegation of insufficient VCAA notice or shown that any such error is unduly prejudicial, meaning outcome determinative of her claims. VA also fulfilled its duty to assist the Veteran by obtaining all relevant evidence in support of her claims, which is obtainable, and therefore appellate review may proceed without prejudicing him. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159; see also Bernard v. Brown, 4 Vet. App. 384 (1993). A review of the claims file shows that VA has conducted reasonable efforts to assist her in obtaining the evidence necessary to substantiate her claims during the course of this appeal. The AOJ/RO has obtained available service treatment records, service personnel records, VA and identified private treatment records and Social Security Administration (SSA) disability records. The Veteran also submitted additional records and written statements in support of her claims. It appears that some of the Veteran's service treatment records are missing, despite several attempts by the AOJ/RO to obtain them, even upon remand by the Board. When service treatment records are lost or missing, through no fault of the Veteran, VA has a heightened obligation to consider the applicability of the benefit of the doubt rule, to assist the claimant in developing the claim, and to explain its decision. See Cuevas v. Principi, 3 Vet. App. 542, 548 (1992); O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). No presumption, however, either in favor of the claimant or against VA, arises when there are lost or missing service records. See Cromer v. Nicholson, 19 Vet. App. 215, 217-18 (2005) (Court declined to apply "adverse presumption" against VA where records had been lost or destroyed while in Government control because bad faith or negligent destruction of the documents had not been shown). Moreover, the mere fact that these records are unavailable for consideration, while indeed unfortunate, does not obviate the need for the Veteran to still have medical nexus evidence supporting her claims by suggesting a correlation between her currently claimed conditions and her military service. In other words, missing records concerning her service, either service treatment records (STRs) or service personnel records (SPRs), do not lower the threshold for an allowance of her claims. The legal standard for proving a claim is not lowered; rather, the Board's obligation to discuss and evaluate evidence is heightened. Notably, the Board remanded this claim in July 2008 and again in October 2011 for the AOJ to ascertain the existence of any outstanding service treatment records, but none appears to be available. Indeed, the AOJ notified the Veteran of these missing service treatment records in a December 2011 notice, and asked the Veteran to send any still in her possession, but received no response from the Veteran. The AOJ also issued a September 2012 memorandum that rendered a formal finding of the unavailability of the missing service treatment records. The Board concludes that all procedures to obtain any missing service treatment records were correctly followed. Since all efforts have been exhausted, further attempts would be futile. 38 C.F.R. § 3.159(c)(2), (3). Next, a specific VA medical examination was obtained in October 2010 to assess the nature and etiology of her claimed bilateral carpal tunnel syndrome. However, the examiner found no present left and right carpal tunnel syndrome. Also, a specific VA medical examination was obtained in November 2010 to assess the nature and etiology of her status-post salpingo-oophorectomy, but this examiner also found no present disability. To that end, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that these examinations were more than adequate in that they were based on a review of the entire claims file, consideration of the lay testimony of record, and clinical examinations/testing. Moreover, without meeting the preliminary element of service connection for a current disability, there was no basis or need for the examiners to also comment on the etiology of non-existent disabilities for left and right carpal tunnel syndrome and status-post salpingo-oophorectomy. Importantly, these conditions are not readily amenable to lay diagnosis or comment on etiology, in contrast with other conditions within the realm of lay observation and experience (e.g., a separated shoulder or broken arm, varicose veins, tinnitus (ringing in the ears), or pes planus (flat feet), etc.). See Colantonio v. Shinseki, 606 F.3d 1378 (Fed. Cir. 2010), citing Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010) (medically competent evidence is not required in every case to "indicate" that the claimant's disability "may be associated" with her service). The Board is not obligated to request an opinion when there is no suggestion of a disease or injury in service that could be associated with the currently claimed disabilities. Charles v. Principi, 16 Vet. App. 370 (2002). As such, another VA C&P examination and medical nexus opinion is not warranted. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to these issues on appeal has been met. 38 C.F.R. § 3.159(c)(4). In compliance with the Board's October 2011 remand directive, the AOJ obtained the Veteran's outstanding VA treatment records that are relevant to the claims decided in the present appeal; and these are associated in electronic form in her Virtual VA file. (The Board is remanding the psychiatric disability claim because the Veteran identified still other VA treatment records that are pertinent to only that particular claim). Also, as mentioned, the AMC confirmed that her remaining service treatment records remain unavailable and further search efforts would be futile. The Board is therefore satisfied there was substantial compliance by the AMC with the prior remands. See Stegall v. West, 11 Vet. App. 268 (1998) and Dyment v. West, 13 Vet. App. 141, 146- 47 (1999). The Board concludes that all available records and medical evidence has been obtained in order to make an adequate determination as to these claims. Hence, no further notice or assistance is required to fulfill VA's duty to assist 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). Therefore, the Board finds that VA has complied with the duty-to-assist requirements. 38 U.S.C.A. § 5103A. II. Analysis-Service Connection for Right and Left Carpal Tunnel Syndrome, Status Post Salpingo-Oophorectomy and Hypertension 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 may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in- service disease or injury and the present disease or injury. 38 U.S.C.A. § 1112; 38 C.F.R. § 3.304. See also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996) [(table)]. Alternatively, service connection may be established under 38 C.F.R. § 3.303(b) by (a) evidence of (i) the existence of a chronic disease in service or during an applicable presumption period under 38 C.F.R. § 3.307 and (ii) present manifestations of the same chronic disease, or (b) when a chronic disease is not present during service, evidence of continuity of symptomatology. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). A. Right and Left Carpal Tunnel Syndrome and Status Post Salpingo-Oophorectomy The Veteran attributes her carpal tunnel syndrome to years of working as a typist during service. She also claims her gynecological condition of status post salpingo-oophorectomy is due to having her right fallopian tube and/or right ovary removed during service. As discussed above, few service treatment records are available for this Veteran. At the July 2003 service discharge examination, concerning the claimed gynecological condition, the Veteran reported she had "removal of philobian [sic] tube;" and the examiner found she is status-post right salpingo-oophorectomy for pelvic adhesions, but also noted there were no records for review. Concerning the claimed carpal tunnel syndrome of her wrists, she reported to the examiner that she had wrist pain since 1999; and the examiner objectively noted as "wrist pain in past" decreased with physical therapy. This evidence notwithstanding, the Veteran's claim fails to meet the preliminary requirement for service connection, namely showing of a current disability. Fundamental to the claim is that the Veteran first has to establish she has a chronic disability. See Brammer v. Derwinski, 3 Vet. App. 223 (1992); and Degmetich v. Brown, 8 Vet. App. 208 (1995); 104 F.3d 1328, 1332 (1997) (holding that VA compensation only may be awarded to an applicant who has disability existing on the date of application, not for past disability). See also McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (further clarifying that this requirement of current disability is satisfied when the claimant has the disability at the time the claim for VA disability compensation is filed or during the pendency of the claim and that a claimant may be granted service connection even though the disability resolves prior to VA's adjudication of the claim). Upon physical examination, the October 2010 VA examiner found no evidence of a nerve disorder of the wrists; and concluded there was no evidence of bilateral carpal tunnel syndrome in service or currently. Upon ordering nerve conduction study/electromyograph testing in November 2010, the consulting neurologist found no electrodiagnostic evidence of median neuropathy at the wrists. The November 2010 VA gynecological examiner assessed the Veteran as still having her right ovary and that it was unlikely she underwent a right salpingo-oophorectomy in the past, noting that her medical records do not confirm such operation and her own personal history concerning this was vague. The examiner reasoned that no documentation exists for a salpingectomy (surgical treatment of ectopic pregnancies). Referencing a VA treatment record, the examiner noted that she was clinically shown in November 2009 to have both ovaries with follicles. The examiner found the Veteran is clearly able to become pregnant due to a 2009 positive pregnancy test with subsequent miscarriage. In this case, there is no competent and credible evidence showing that the Veteran presently has a chronic disability for any of the above claimed disabilities. Since the time the Veteran filed her claim in August 2003 and/or at any time during the pendency of the appeal, a review of her VA treatment records, private treatment records and SSA disability records do not reveal diagnoses for any right and left carpal tunnel syndrome and status post salpingo-oophorectomy, or other indication of such disabilities. So, the overall medical evidence weighs against the possibility that she presently has right and left carpal tunnel syndrome and status post salpingo-oophorectomy. The Board acknowledges that the Veteran is competent to have experienced a continuity of symptoms since service, such as wrist pain. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Barr , 21 Vet. App. 303; and 38 C.F.R. § 3.159(a)(2). Still, if she were to assert continuity of symptomatology since service, she is not competent to ascribe these symptoms to a particular diagnosis of a right and left carpal tunnel syndrome and status post salpingo-oophorectomy, or other chronic gynecological disability; or attribute her current symptoms to her active duty service. Rather, specialized medical expertise as well as independent physical evaluation and diagnostic testing (such as performed by the October and November 2010 VA examiners) are required to diagnose these disabilities. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (certain disabilities are not conditions capable of lay diagnosis); but see Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009) (clarifying that medical evidence is not always or categorically required in every instance to establish the required nexus or linkage between the claimed disability and service or a service-connected disability). The Board finds the Veteran is not competent to self-diagnose right and left carpal tunnel syndrome and status post salpingo-oophorectomy. This requires medical expertise that the Veteran fails to possess. Since the Board does not find the Veteran's lay statements to be competent to establish the missing element of a present disability for these claims, there is no need to consider the credibility of her lay statements in this regard, even though this, too, affects its ultimate probative value. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The Board, however, finds her statements as to having undergone a salpingo-oophorectomy to be not credible in light of the overall evidence of record. Because there is no diagnosis of right and left carpal tunnel syndrome and status post salpingo-oophorectomy, or other competent and credible evidence the Veteran has these conditions, there is no possible means of attributing these such disorders to her military service. In light of the above discussion, the Board concludes that the evidence does not support the claims for service connection and there is no doubt to be otherwise resolved. As such, the appeal is denied. B. Hypertension The Veteran contends she developed hypertension during her active duty military service and emphasizes that she was prescribed medication for hypertension during service. Certain chronic diseases, including hypertension, will be presumed to have been incurred in service if manifested to a compensable degree of at least 10 percent within one year after service. This presumption, however, is rebuttable by probative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Initially, the Veteran's recent VA and private medical records show diagnoses of hypertension, so the Board does not dispute she presently has hypertension. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000). There is some indication of in-service incurrence of hypertension, due to high blood pressure readings at discharge and associated prescription medication during service. The July 2003 separation examination report assessed blood pressure readings of 179/108, 181/110 and 170/95. The examiner provided a diagnosis of hypertension and noted that the Veteran stated she forgot to take her prescription medications for hypertension that day. The October 2010 VA examiner noted elevated blood pressure findings upon separation examination, but that it was not clear if they were related to essential hypertension or substance abuse issues. Importantly, the record shows by objective evaluation that she manifested hypertension to a compensable degree of 10 percent during service, at the time of the discharge examination. Hypertension for VA purposes is established if the diastolic blood pressure is 90mm. or more, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160mm. or greater with a diastolic pressure of less than 90mm. 38 C.F.R. § 4.104, Diagnostic Code 7101. At the discharge examination, she exhibited three separate blood pressure readings of over 160 mm. systolic pressure and over 90 mm. diastolic pressure, thus meeting the rating criteria for a compensable, 10 percent evaluation for hypertension. Resolving any doubt in favor of the Veteran, there is sufficient indication of entitlement to presumptive service connection for chronic diseases, under 38 C.F.R. § 3.309(a), to warrant a grant of service connection for hypertension. ORDER The claim for service connection for right carpal tunnel syndrome is denied. The claim for service connection for left carpal tunnel syndrome is denied. The claim for service connection for status post salpingo-oophorectomy is denied. The claim for service connection for hypertension is granted. REMAND Unfortunately, a remand is required for the remaining issues of entitlement to service connection for macules on the tongue, asthma, chronic bronchitis, chronic sinusitis, chronic heart disability manifested by a heart murmur, bilateral pes planus, a chronic low back disability, and a psychiatric disability, including PTSD and bipolar disorder. Although the Board sincerely regrets the additional delay, it is necessary to ensure that there is a complete record upon which to decide the Veteran's claims so that she is afforded every possible consideration. VA has a duty to make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claim for the benefits sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. I. Outstanding Treatment Records First, the AOJ needs to obtain outstanding VA and private psychiatric treatment records, which are relevant to the Veteran's psychiatric disability claim. The Veteran has identified VA psychiatric treatment records that are relevant to her claim. In her February 2012 statement, she reported that she was concurrently receiving treatment in an 11-week PTSD treatment program, and provided an address matching the VA Boston Healthcare System, Brockton Campus in Brockton, Massachusetts. The Board notes that records generated by VA facilities that may have an impact on the adjudication of a claim are considered constructively in the possession of VA adjudicators during the consideration of a claim, regardless of whether those records are physically on file. Dunn v. West, 11 Vet. App. 462, 466-67 (1998); Bell v. Derwinski, 2 Vet. App. 611, 613 (1992). The AOJ should obtain and associate with the claims file the identified VA treatment records from VA Boston Healthcare System, Brockton Campus, especially those dated since February 2012. Also, Virtual VA contains VA treatment records at the West Haven VAMC, which in turn reference the Veteran's psychiatric hospitalization at the Yale Psychiatric Hospital in August 2012. On remand, the AOJ should request the Veteran to fill out the proper authorization form so that the pertinent records during that timeframe may be obtained. Any additional VA and private psychiatric treatment records that are potentially relevant would need to be obtained before deciding her appeal. II. Medical Opinion for Macules on the Tongue, Asthma, Bilateral Pes Planus, and a Chronic Low Back Disability Although a VA examination was conducted in October 2010 on the nature and etiology of any current macules on the tongue, asthma, bilateral pes planus, and low back disability, the examiner's findings require further explanation. When VA undertakes to examine a Veteran, VA is obligated to ensure that that examination is adequate. See Barr, 21 Vet. App. 303. Inadequate medical examinations include examinations that contain only data and conclusions, do not provide an etiological opinion, are not based upon a review of medical records, or provide unsupported conclusions. Nieves- Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). An additional medical comment is required to assist in making determinations regarding the nature and etiology of the Veteran's macules of the tongue, asthma, bilateral pes planus and a chronic low back disability, especially in terms of whether her military service caused or aggravated these disabilities. See McLendon v. Nicholson, 20 Vet. App. 79 (2006), 38 U.S.C.A. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4). A. Macules of the Tongue Commenting on the claimed macules of the tongue, the October 2010 VA examiner assessed Peutz-Jegher's syndrome, as likely as not a congenital abnormality, which was unlikely exacerbated by service. Generally speaking, a congenital disease or defect is not service connectable as a matter of express VA regulation. 38 C.F.R. §§ 3.303(c), 4.9 (2012). A possible exception is if there is evidence of additional disability due to aggravation during service of the congenital disease, but not defect, by superimposed disease or injury. VAOPGCPREC 82-90; Quirin v. Shinseki, 22 Vet. App. 390 (2009); Monroe v. Brown, 4 Vet. App. 513, 514-15 (1993); Carpenter v. Brown, 8 Vet. App. 240, 245 (1995); VAOPGCPREC 67-90; and VAOPGCPREC 11-99. See also Winn v. Brown, 8 Vet. App. 510, 516 (1996). Here, the examiner did not provide any rationale for the conclusion that the Veteran has this particular congenital disease nor that it was not exacerbated by service. On remand, the examiner must elaborate on the reasoning for such conclusions. B. Bilateral Pes Planus Here, the October 2010 examiner diagnosed preexisting bilateral pes planus, based upon notation on the December 1988 enlistment examination, with no evidence of exacerbation during service. Especially in light of the Veteran's missing service treatment records, the examiner's conclusion against the possibility of aggravation seems inadequate. In providing an addendum opinion, the examiner should consider the Veteran's lay statements of foot pain during and since service when considering possibility of aggravation of preexisting bilateral pes planus. See Jandreau, 492 F.3d 1372; Barr, 21 Vet. App. 303; 38 C.F.R. § 3.159(a)(2). C. Asthma In this case, the October 2010 VA examiner found the Veteran's asthma to be a pre-existing disability, based on her report of childhood asthma on a January 1989 service dental health questionnaire and that there is no current evidence that service exacerbated this condition. On the January 1989 service dental record, the Veteran reported "asthma as a child" and "asthmatic wheezing on occasion-last attack March." However, these reports of prior medical conditions do not amount to a "noted" condition of pre-existing asthma or bilateral pes planus upon entry, because there is no indication that the service clinicians independently found these conditions pre-existed entry into service. VA law provides that a veteran is presumed to be in sound condition, except for defects, infirmities or disorders noted when examined, accepted, and enrolled for service, or where clear and unmistakable evidence establishes that an injury or disease existed prior to service and was not aggravated by service. 38 U.S.C.A. §§ 1111, 1132 (West 2002); 38 C.F.R. § 3.304(b) (2012). A preexisting injury or disease will be considered to have been aggravated by active military service, where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. Aggravation may not be conceded, however, where the disability underwent no increase in severity during service. 38 U.S.C.A. § 1153 (West 2002); 38 C.F.R. § 3.306 (2012). The term "noted" denotes only such conditions that are recorded in examination reports. The existence of conditions prior to service reported by the Veteran as medical history does not constitute a notation of such conditions, but will be considered together with all other material evidence in determining the question of when a disease or disability began. Here, the October 2010 VA examiner did not provide sufficient rationale for the conclusion that the Veteran has preexisting asthma, aside from an isolated reported history on a service dental record. In contrast, the December 1988 enlistment examination did not note a disability of asthma, but the October 2010 examiner did not discuss this fact. Thus, it would be helpful for the examiner to elaborate on the medical basis for considering asthma a preexisting disability, and to also comment on the possibility that her asthma was directly etiologically linked to service. The examiner must also give adequate consideration to the Veteran's competent lay statements of a long history of breathing problems dating back to service and to address whether chronic bronchitis and/or chronic sinusitis were incurred as a result of active service. The Board notes that at her July 2003 service discharge examination the Veteran reported she had bronchitis since 2000, sinusitis since 2002, wheezing and hay fever, and breathing problems associated with exercise since 2000. The examiner noted a positive smoking history, and history of bronchitis and asthma, but did not objectively assess any diagnosis for chronic bronchitis or chronic sinusitis. Rather, clinical evaluation of the sinuses and lungs and chest was "normal." The October 2010 VA examiner found it as likely as not that the Veteran had isolated bronchitis and sinusitis, and attributed the sinus symptoms to isolated upper respiratory infections. It is not entirely clear what the rationale is for this finding against a current chronic disability of bronchitis and/or sinusitis. D. Chronic Low Back Disability The October 2010 VA examiner provided a negative etiological opinion against the possibility that a chronic low back disability was causally related to service. Specifically, the examiner stated: Lumbar back strain as likely as not with L1 compression deformity, of unknown onset. Mild functional impairment as subjectively reported. At time of separation physical examination, Veteran reports back pain and [physician] note documents episodic back pain, uses over-the-counter medications. This is not suggestive of a chronic low back condition. The Board finds the examiner's rationale unclear. In particular, the conclusion appears to be inconsistent with the reports of a continuity of low back pain. On remand, a clearer statement of the opinion and accompanying rationale is requested. The examiner must also give adequate consideration to the Veteran's competent lay statements of a continuity of back pain dating back to service. III. VA Examination and Medical Opinion for Chronic Heart Disability Manifested by a Heart Murmur The Veteran contends that she developed a heart disorder and heart murmur from service because she did not have these conditions before entering service. As discussed above, few service treatment records are available for this Veteran. However, the July 2003 discharge examination is available. At that examination, concerning the claimed heart disability, she was assessed with "a probable innocent murmur" and clinical evaluation of the heart was "abnormal." The Board additionally notes a February 2001 private EKG report, contemporaneous with active duty service, which showed sinus tachycardia, left atrial enlargement, and septal infarction. So, there are indications of in-service incurrence of a chronic heart disability, as recently as 2003. Here, the October 2010 VA examiner found no indication of a chronic heart disability, noting in the diagnosis section that there is no current evidence of any significant cardiac murmur stemming from service. In coming to this conclusion, the examiner noted that the Veteran did not have angina or shortness of breath at the time of the examination, but did not discuss the Veteran's competent lay statements of a history of shortness of breath and rapid heartbeat. Hearing Transcript (T.) at 11. Since her allegations of these particular symptoms also appear to be uncontradicted, even by medical findings of record, these lay assertions are found to be credible, and consequently, are also probative. Thus, it is not clear whether the October 2010 VA examiner thoroughly and adequately considered the Veteran's competent and credible statements. Inadequate medical examinations include examinations that contain only data and conclusions, do not provide an etiological opinion, are not based upon a review of medical records, or provide unsupported conclusions. In contrast, earlier in the record, there is a January 2007 VA Echo consultation report of record, which found mild concentric left ventricular hypertrophy with grade 1 diastolic dysfunction of the left ventricle. Therefore, the Board finds a remand is necessary for another VA heart examination to clarify the nature of the Veteran's current chronic heart disability; and to obtain a medical opinion on whether her current heart disability is etiologically linked to service, including consideration of the Veteran's credible history of heart-related symptoms. Accordingly, the case is REMANDED for the following action: 1. Ask the Veteran whether there are any additional VA or private treatment records that need to be obtained and considered in her appeal. In particular, ask the Veteran to complete and return the necessary authorization (VA Form 21-4142) for VA to obtain the medical treatment records from the Yale Psychiatric Hospital, especially dated since August 2012 to the present; and any other outstanding private treatment records. If she provides a completed release form authorizing VA to obtain these confidential treatment records, then attempt to obtain them with at least one follow-up request if no reply is received. See 38 C.F.R. § 3.159(c)(1). Then obtain any outstanding VA psychiatric treatment records from the VA Boston Healthcare System, Brockton Campus, in Brockton, Massachusetts, especially dated since February 2012 to the present. 2. Thereafter, request a supplemental or addendum opinion from the VA clinician who provided the October 2010 VA compensation medical examination and opinion report. The claims file, including a complete copy of this remand, must be made available for review of the Veteran's pertinent medical history. In the event the October 2010 VA examiner is unavailable or unable to provide a supplemental opinion, then schedule the Veteran for an appropriate VA compensation examination, to determine the nature and etiology of the Veteran's for macules on the tongue, asthma, bronchitis, sinusitis, bilateral pes planus, and low back disability. All indicated tests and studies, and any other diagnostic procedures deemed necessary, should be conducted. In particular, the examiner is requested to provide a supplemental opinion and rationale on the following: a) Identify all present disabilities associated with the Veteran's claimed for macules on the tongue, asthma, bronchitis, sinusitis, bilateral pes planus, and low back disability. b) Assuming there is a confirmed low back disability, the examiner is then asked to provide an opinion as to whether it is at least likely as not (a 50% or higher degree of probability) that it had its clinical onset during active duty service from 1989 to 2003; or is any such disability otherwise related to such periods of service, including to any in-service injury or disease? The examiner must consider the Veteran's competent assertions of a history of post-service low back pain. c) Assuming there is a confirmed macules of the tongue disability, the examiner is then asked to provide an opinion as to whether it is at least likely as not (a 50% or higher degree of probability) that it is a congenital disease? If so, is there evidence of additional disability due to aggravation during service of the congenital disease, but not defect, by superimposed disease or injury? d) Did any asthma disability diagnosed clearly and unmistakably pre-exist her active duty military service (January 1989 to July 2003)? i) If asthma pre-existed the Veteran's active duty military service (January 1989 to July 2003), was her asthma permanently aggravated during or by her military service beyond its natural progression? ii) If asthma did not preexist the Veteran's active duty service, did it at least as likely as not (a 50% or higher degree of probability) have its clinical onset during active duty service from 1989 to 2003; or is any such disability otherwise related to such periods of service, including to any in-service injury or disease? The examiner must consider the Veteran's competent assertions of a history of breathing problems beginning in service and continuing to the present. e) Assuming there is a confirmed bronchitis and/or sinusitis disability, the examiner is then asked to provide an opinion as to whether it is at least likely as not (a 50% or higher degree of probability) that it had its clinical onset during active duty service from 1989 to 2003; or is any such disability otherwise related to such periods of service, including to any in-service injury or disease? The examiner must consider the Veteran's competent assertions of a history of bronchitis symptoms since 2000 and sinusitis symptoms since 2002. f) Since bilateral pes planus was "noted" as a preexisting disability on the December 1988 enlistment examination, was the Veteran's bilateral pes planus permanently aggravated during or by her military service beyond its natural progression? The examiner must consider that the Veteran has competently asserted a continuity of foot pain beginning in service and continuing to the present. Rationale for all requested opinions shall be provided. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation stating why this is so. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). 3. After the requested development in paragraph #1 is completed, schedule the Veteran for an appropriate VA examination in order to determine the nature and etiology of her claimed chronic heart disability manifested by a heart murmur. It is imperative that the claims file be made available to the examiner and reviewed in connection with the examination. Any medically indicated special tests should be accomplished, and all special tests and clinical findings should be clearly reported. The examiner should respond to the following: a) Please confirm if the Veteran currently has a chronic heart disability to include as manifested by a heart murmur. b) For each disability found, did it at least as likely as not (a 50% or higher degree of probability) have its clinical onset during the Veteran's period of service, or is any such disability otherwise related to such period of service, including to any in-service injury or disease? For the purposes of this examination and opinion, the examiner should presume that the Veteran has credibly asserted post-service continuity of symptoms regarding her claimed heart disability(e.g., chest pain, rapid heartbeat, shortness of breath, etc.). Rationale for all requested opinions shall be provided. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation stating why this is so. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). 4. Ensure that the requested actions have been accomplished (to the extent possible) in compliance with this REMAND. If any action is not undertaken, or is taken in a deficient manner, appropriate corrective action should be undertaken. 5. Then readjudicate the remaining claims in light of any additional evidence. If these claims are not granted to the Veteran's satisfaction, send her a Supplemental statement of the case and give her an opportunity to respond to it before returning the file to the Board for further appellate consideration of these claims. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims 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. 2012). ______________________________________________ T. L. DOUGLAS Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs