Citation Nr: 1306295 Decision Date: 02/22/13 Archive Date: 02/27/13 DOCKET NO. 05-13 830 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for a chronic cardiac disability to include non-ischemic cardiomyopathy and congestive heart failure, to include as secondary to the effects of medications taken for treatment of service-connected disabilities. 2. Entitlement to service connection for a chronic gastrointestinal disability to include gastroenteritis and gastroesophageal reflux disease, to include as secondary to the effects of medications taken for treatment of service-connected disabilities. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD T. Wishard, Counsel INTRODUCTION The Veteran had active military service from July 1959 to July 1984. These matters come before the Board of Veterans' Appeals (Board) from a July 2002 rating decision of the Department of Veterans Affairs (VA), Regional Office (RO) in St. Petersburg, Florida. In February 2004, the Veteran testified before a Decision Review Officer in St. Petersburg, Florida. A transcript of that hearing is of record. In June 2007, the Veteran testified at a Travel Board hearing before the undersigned Veterans Law Judge. A transcript of that hearing is of record. These matters were previously before the Board in March 2008, May 2011, and November 2012 and were remanded for further development. They have now returned to the Board for further appellate consideration. The Board finds that VA has substantially complied with the mandates of the Board's remands and will proceed to adjudicate the appeals. The issue of entitlement to total rating for compensation purposes based on individual unemployability (TDIU) has been raised by the record, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it and it is referred to the AOJ for appropriate action. (See November 6, 2012 VA Form 21-4138 from Veteran.) FINDINGS OF FACT 1. The Veteran is service connected for migraines, chronic lumbar muscle strain, left shoulder arthralgia, left hip arthralgia, right hip arthralgia, right shoulder arthralgia, limitation of flexion of the knee, and sinusitis. 2. The earliest clinical evidence of a cardiac disability is several years after separation from service. 3. There has been no demonstration by competent medical, nor competent and credible lay evidence of record that the Veteran has a chronic cardiac disability, casually related to, or aggravated by, service or a service-connected disability. 4. The most probative clinical evidence of record is against a finding that the Veteran has a chronic cardiac disability caused by, or aggravated by, service or a service-connected disability. 5. The earliest clinical evidence of a chronic current gastrointestinal disability is several years after separation from service. 6. There has been no demonstration by competent medical, nor competent and credible lay evidence of record that the Veteran has a current gastrointestinal disability, casually related to, or aggravated by, service or a service-connected disability. 7. The most probative clinical evidence of record is against a finding that the Veteran has a gastrointestinal disability caused by, or aggravated by, service or a service-connected disability. 8. The Veteran is less than credible with regard to the onset of a current chronic gastrointestinal disability. CONCLUSIONS OF LAW 1. A Chronic cardiac disability, to include non-ischemic cardiomyopathy and congestive heart failure, was not incurred in, or aggravated by, active service, and may not be presumed to have been so incurred or aggravated, nor is it proximately due to, the result of, or aggravated by, service-connected disability. 38 U.S.C.A. §§ 1110, 1112, 1113, 1131, 1137 (West 2002);38 C.F.R. § 3.303, 3.304, 3.307, 3.309, 3.310 (2012). 2. A chronic gastrointestinal disability, to include gastroenteritis and gastroesophageal reflux disease (GERD) was not incurred in, or aggravated by, active service, nor is it proximately due to, the result of, or aggravated by, service-connected disability. 38 U.S.C.A. §§ 1110, 1112, 1113, 1131, 1137 (West 2002);38 C.F.R. § 3.303, 3.304, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). See also Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Dingess v. Nicholson, 19 Vet. App. 473 (2006). Notice was provided to the Veteran in December 2001, September 2003, May 2005, and July 2008. VA also has a duty to assist the Veteran in the development of the claims. The claims file includes service treatment records (STRs), Social Security Administrative (SSA) records, VA and private medical records, and the statements of the Veteran in support of his claims. The Board has considered the statements and perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claims for which VA has a duty to obtain. The claims file includes statements from various clinicians that they do not have records for the Veteran (See responses from Dr. J.C. of St. Petersburg, Florida, Dr. S. of Miami, Florida., and Dr. S. of Orange Park, Florida.) VA examinations/opinions were obtained in July 2011 and December 2012. 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 the VA examinations/opinions obtained in this case are adequate, as the opinions are predicated on a review of the claims file to include the Veteran's STRs, and private medical records. They consider the pertinent evidence of record, to include statements of the Veteran regarding his symptoms. Rationale was provided for the opinions proffered. Based on the foregoing, the Board finds that all relevant facts have been properly and sufficiently developed in this appeal and no further development is required to comply with the duty to assist the Veteran in developing the facts pertinent to the claims. Essentially, all available evidence that could substantiate the claims has been obtained. Legal Criteria Service Connection Establishing service connection generally requires medical evidence or, in certain circumstances, lay evidence of the following: (1) A current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) nexus between the claimed in-service disease and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed.Cir.2007); Hickson v. West, 12 Vet. App. 247 (1999); Caluza v. Brown, 7 Vet.App. 498 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table). Pursuant to 38 C.F.R. § 3.303(b), a claimant may establish the second and third elements by demonstrating continuity of symptomatology. See Barr v. Nicholson, 21 Vet.App. 303 (2007). Continuity of symptomatology can be demonstrated by showing (1) that a condition was "noted" during service; (2) evidence of continuous symptoms after service; and (3) medical, or in certain circumstances, lay evidence of a nexus between the current disability and the post service symptoms. Savage v. Gober, 10 Vet.App. 488 (1997). In each case where service connection for any disability is being sought, due consideration shall be given to the places, types, and circumstances of such Veteran's service as shown by such Veteran's service record, the official history of each organization in which such Veteran served, such Veteran's medical records, and all pertinent medical and lay evidence. 38 U.S.C.A. § 1154(a) (West 2002). Under 38 C.F.R. § 3.310, service connection may be granted for disability that is proximately due to or the result of a service-connected disease or injury, or for the degree of disability resulting from aggravation of a nonservice-connected disability by a service-connected disability. See also Allen v. Brown, 7 Vet. App. 439, 448 (1995). Analysis The Board has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the medical evidence pertinent to the claims on appeal. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the U.S. Court of Appeals for the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims. Cardiac disability Direct Basis The Veteran has diagnoses of non-ischemic cardiomyopathy and congestive heart failure; thus, an element of entitlement to service connection, a current disability, has been met. A second element of entitlement to service connection is an in-service injury or disease. The Veteran's STRs reflect that in April 1971, he had complaints of chest soreness; a virus syndrome was noted. Clinical records reflect that in May 1984, the Veteran sought treatment for chest pains and was hospitalized from May 14 to May 21, 1984. A May 27, 1984 STR consultation sheet reflects that there was no objective evidence of a myocardial infarction. A June 1984 Narrative Summary (Clinical Resume), indicates that the Veteran was well, concerning cardiac-related concerns, until the morning of hospital admission in May of 1984 when he developed heavy substernal pressure. The Veteran reported that the pain radiated around both sides of the chest towards the back. When the Veteran presented to the emergency room, the impression was that he had had acute myocardial ischemia. The Veteran was noted to be very pale, writhing in the hospital bed in pain, and had marked xanthelasma. A cardiogram was normal. Due to the extent of the Veteran's symptoms, a streptokinase drip was begun; however, the record reflects that the physician "did not pursue the streptokinase because several cardiograms done over that hour did not document any evidence of myocardial ischemia and [the physician] did not feel that there was enough evidence to warrant further use of streptokinase or a heparin drip." Clinical records reflect that EKG, enzymes and stress tests suggested no myocardial infarction had occurred. The discharge diagnosis was "chest pain, [myocardial infarction] ruled out." A June 1, 1984 STR reflects that the Veteran's oral cholecystrogram showed poor visualization and an ultrasound showed gallstones. It was noted that a myocardial infarction was ruled out during his recent hospitalization from May 14 to May 21, 1984. The impression was "recent episode of severe chest pain. There is no evidence of myocardial infarction. [Negative] stress test would preclude diagnosis of [arteriosclerotic heart disease] although he certainly has several risk facts (smoking hyperlipedemia). It was recommended that he have a surgical evaluation of the gall bladder. A June 14, 1984 narrative summary (clinical resume) reflects that the Veteran had cholelithiasis. It was noted that the Veteran had continued intermittent substernal pain since his hospitalization in May 1984 for the originally suspected myocardial infarction. The Veteran denied any symptoms of acid reflux. The Veteran was discharged from active service in July 1984. Post-service medical records include a June 1985 private discharge summary for May 1985 treatment. It was noted that, due to the Veteran's riding in helicopters and involvement with "Search and Rescue", it was felt that the Veteran should be certain about his cardiac system. Upon clinical examination, it was noted that his cardiovascular examination was normal. His resting cardiogram was normal. His blood work was normal. A cardiac cauterization was performed "without difficulty." It was noted that the left ventricle was "probably normal, and certainly the coronary arteries were normal with no evidence of spasm. [The Veteran] was therefore discharged as chest pain - [not yet diagnosed], but no cardiac cause found." Correspondence from the Medical Consultants Group, dated in July 1985, reflects that the Veteran's "cardiac catherization was normal. He subsequently had an upper G.I. endoscopy by [T.H.] which showed only mild duodenitis. He continues to have the sensation in his left parasternal area as well continues to have episodic jabs in his his [sic] chest radiating into his left arm, lasting no more than 30 seconds. These are unrelated to exertion. I really have no idea what could be causing these things. However we found nothing serious." An August 1985 VA outpatient health record reflects complaints of a torn muscles in the left upper chest wall. The assessment was strained pectoralis. A May 1987 private record from the outpatient department of Grace Hospital reflects that the Veteran was assessed for chest pain and left arm discomfort. It was noted that two years earlier, he was evaluated for chest pain and his coronary arteries were all perfectly normal. Upon examination, it was noted that his electrocardiogram was perfectly normal and similar to that of the tracings in the past. The examiner noted "I do not feel that his pain is cardiac in origin. It certainly sounds musculoskeletal with his immediate onset, tenderness over the area and he also states it is relieved somewhat by resting his left arm over his chest." An October 1989 private medical record shows that complaints of chest pain were determined to be chest wall in origin. It was noted that he had had a normal coronary angiogram four years earlier. January 1990 records from the Florida Medical Center reflect that a single portable radiograph of the Veteran's chest showed that the Veteran's heart was not enlarged. The echocardiogram reflected that the Veteran had a normal size left atrium and left ventricular cavity dimension, normal motion of septum and posterior wall, normal size aorta with aortic cusp separations, no pericardial effusion, and normal mitral valve. The echocardiogram was within normal limits. The impression was antral gastritis and duodenitis. Another record reflects that the EKG showed ischemia. An October 1998 private cardiology consultation report shows that the Veteran reported that he had a prior history of a myocardial infarction going back to 1984, and, apparently, a second one in 1990. The physician commented that the Veteran had chest pain compatible with ischemia and a left bundle branch block. Private medical records dated in 1999 and 2000 reflect non-ischemic cardiomyopathy, chronic left bundle branch block, global left ventricular hypokinesis with an ejection fraction of 25 percent, septal and apical attenuation without ischemia by exercise. The assessment was severe cardiomyopathy. He also had an assessment of congestive heart failure. (See January and October 2000 private medical record.) An April 2001 private office visit note reflects an assessment of non-ischemic cardiomyopathy with coronary disease. A September 2001 private office visit note reflects an assessment of stable ischemic cardiomyopathy with mild coronary disease. A February 2002 report from C. Medical Group reflects that the Veteran has congestive heart failure secondary to viral cardiomyopathy. The Veteran was afforded a VA examination in June 2002; however, the examiner stated that he had reviewed only portions of the claims file. The examination report shows that the Veteran had many risk factors for cardiovascular disease. The diagnosis was congestive, nonischemic cardiomyopathy, with intermittent episodes of moderate congestive heart failure and mild chronic congestive failure. The June 2002 VA examiner noted, "[i]n May of 1984 just prior to leaving the service, [the Veteran] was hospitalized in Boston, Massachusetts. He spent one week in the CICU, was diagnosed as having had a myocardial infarction and treated with streptokinase. It was reported to him that they opened his coronary artery thrombosis and after he was discharged, he went on to retire in August of that year, approximately three months later." The Board finds, based on a review of the clinical records, that the medical history noted in the June 2002 report is inaccurate. As discussed above, the clinical record reflects that the Veteran did not have a myocardial infarction in May 1984. In addition to his admission that he did not review the complete record, the inaccurate finding by the examiner that the Veteran had a myocardial infarction in May 1984, is evidence of such lack of review. A February 2003 SSA Disability Determination and Transmittal form reflects that the Veteran was determined to have been disabled from April 1999. A primary diagnosis of coronary artery disease was provided, along with a secondary diagnosis of history of congestive heart failure. A May 2007 private office visit record reflects that the Veteran had been more physically active than usual and began experiencing left sided chest discomfort, and pressure-like sensation with occasional radiation through to his back. The assessment was musculoskeletal chest discomfort. The Veteran testified at the February 2004 DRO hearing that he had a heart attack in May 1984 while in service. (See DRO hearing transcript page 2.) The Veteran testified at the June 2007 Board hearing that in May 1984 he experienced pain in his chest which felt as if an anchor had been dropped on his chest, or as if he had fence post stuck through his chest and coming out his back. He further testified that five of the nine cardiologists at South Shore Hospital said that he had a heart problem "to the point that they warned" his family that the drug which they were going to administer, Streptokinase, might kill him. (See Board hearing transcript pages 5 and 11.) The Board acknowledges that the Veteran had severe pain in May 1984 and that clinical personnel initially considered whether he had had a myocardial infarction; however, as noted above, the numerous diagnostic tests ruled out a myocardial infarction. The Board also acknowledges that the Veteran is competent to report what he has been told by a clinician. While, the Veteran may have been initially told by clinicians that he had had a myocardial infarction in May 1984, by the time of his hospital discharge, the diagnostic tests and clinical records reflected that a myocardial infarction had been ruled out. The Board finds that the May 1984 and June 1984 clinical records which ruled out a myocardial infarction are more probative than the Veteran's allegation that he had a myocardial infarction. (See Robinette v. Brown, 8 Vet. App. 69, 77 (1995), "the connection between what a physician said and the layman's account of what he purportedly said, filtered as it was through a layman's sensibilities, is simply too attenuated and inherently unreliable to constitute 'medical' evidence.") A July 2011 VA examination report is of record. It reflects diagnoses of residuals, status post pacemaker for left bundle branch block with non-ischemic cardiomyopathy with distal heart block. The examiner opined that the Veteran's diagnosed heart-related disorders were not caused by or a result of symptoms documented during the Veteran's active duty service. The examiner observed that, while in service, the Veteran had been evaluated on several occasions for "chest pain," but that there was no objective evidence that the Veteran's current cardiac disorder had its onset in military service; and therefore a nexus could not be made. A December 2012 VA examination report reflects the opinion of the clinician as follows: [The] Veteran's Coronary artery disease and cardiomyopathy are not casually or etiologically related to his military service. Rationale: While the veteran certainly had a dramatic episode in May of 1984 and the symptoms were severe and frightening and worrisome to all concerned for acute myocardial infarction, there is no objective evidence that the veteran had an MI that date. He firmly believes he had a heart attack but the objective evidence is that he did not have a heart attack. Cardiac enzymes and EKGs were normal, subsequent stress test was normal indicating no coronary artery disease. The Veteran may sincerely believe that he has a cardiac disability due to service, or to a service connected disability. He is competent to relate his symptoms, such as pain. However, the Veteran has not been shown to possess the requisite training or credentials needed to render a competent opinion as to medical diagnosis or causation in matters of the heart. The Board finds it noteworthy that even medical professionals in 1964 were unsure as to whether the Veteran had had a myocardial infarction until diagnostic testing proved that he had not. Pain in the chest, which may be related to a myocardial infarction in some cases, may be unrelated to a myocardial infarction or cardiac disability in other cases. (e.g. strained pectoralis, chest wall injury, costochondritis). Based on the foregoing, the Board finds that the Veteran's opinion does not constitute competent medical evidence and lacks probative value. see Kahana v. Shinseki, 24 Vet.App. 428, 435 (2011),. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer)." The Board finds that service connection for a cardiac disability is not warranted on a direct incurrence or presumptive basis. The earliest clinical evidence of a current heart disability is more than 10 years after separation from service. The lapse of time between service separation and the earliest documentation of current disability is a factor for consideration in deciding a service connection claim. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). Moreover, there is no competent credible evidence of continuity of symptomatology since service. Although the Veteran had chest pains in service and in the year after service, those pains were not found, by clinical examination and diagnostic testing, to be cardiac in nature. Finally, the probative clinical opinion with regard to the etiology of the Veteran's current heart disabilities is that they are not causally related to active service. The Board has considered the doctrine of giving the benefit of the doubt to the appellant, under 38 U.S.C.A. § 5107 (West 2002), and 38 C.F.R. § 3.102 (2010), but does not find that the evidence is of such approximate balance as to warrant its application. Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Secondary Basis Service connection on a secondary basis requires that the current disability was either caused, or aggravated by, a service-connected disability. Harder v. Brown, 5 Vet. App. 183, 187-89 (1993). The Veteran is service connected for migraines, chronic lumbar muscle strain, arthralgia left shoulder, left hip arthralgia, right hip arthralgia, arthralgia of the right shoulder, limitation of flexion of the knee, and sinusitis. In an October 2012 Written Brief Presentation, the Veteran's accredited representative contended that the Veteran may have a heart disability related to his use of medications which he has taken for treatment of his service-connected disabilities. The Veteran's representative specifically argued that the Veteran's use of "NSAIDS" (non-steroidal anti-inflammatory drugs) for treatment of his service-connected orthopedic-based disabilities and migraines caused the Veteran to develop heart-related problems. The representative referred to a website from Harvard University, one from the United Kingdom, and one from "webmd". (See October 2012 Written Brief Presentation.) The United Kingdom website provided general information that non-steroidal anti-inflammatory drugs (NSAIDs) may have harmful side effects when taken in combination with other medicines. The Harvard website provided information that "cardiovascular risks associated with traditional NSAIDs are small, but worth being aware of." It noted that, in general, cardiovascular side effects are most likely to happen in people with existing heart disease or those at high risk for it. The "webmd" website provided a general discussion on hyperlipoproteinemia Type IV, an inherited metabolic disorder that is characterized by increased blood levels of the triglyceride form of fat that makes up very low-density lipids (VLDL). It was noted that "abnormally high blood levels of triglycerides or cholesterol (another form of blood plasma fat) may be the result of poor dietary habits, genetic causes, or other metabolic disorders or a side effect of certain drugs." Assuming, arguendo, that the articles rise to the level of a medical article or medical treatise, the Board notes that the Court has held that a medical article or treatise "can provide important support when combined with an opinion of a medical professional" if the medical article or treatise evidence discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least "plausible causality" based upon objective facts rather than on an unsubstantiated lay medical opinion. Mattern v. West, 12 Vet. App. 222, 228 (1999). See also Sacks v. West, 11 Vet. App. 314 (1998); Wallin v. West, 11 Vet. App. 509 (1998). In short, articles and treatises tend to be general in nature and tend not to relate to the specific facts in a given veteran's claim. In the present case, the articles submitted by the appellant fall into this general category. Although two of the websites discuss NSAIDs and their potential side effects and interaction with other drugs, none of the websites listed by the accredited representative pertains specifically to this Veteran, and the website information is are not combined with any opinion of a medical professional. The websites are general information websites and do not provide in-depth information on factors such as duration of taking medication, dosage of medication, and percentage of likely of a chronic worsening of a heart disability due to medication. As noted above, the claims file includes a December 2012 opinion from a VA clinician. The clinician opined as follows: Veterans Coronary artery disease and cardiomyopathy are not caused or chronically worsened by his taking NSAIDS for treatment of service-connected disabilities. Rationale: There is no medical literature support for the clam that NSAIDS cause Coronary artery disease or cardiomyopathy. While there is evidence that some individuals on NSAIDS can have increase in heart failure symptoms through complicated mechanisms that involve retention of salt and water, there is no objective evidence that this is [the] case for this veteran. Veterans cardiomyopathy has actually improved over time. His CAD has not appreciably worsened although one would expect some worsening with time, aging, and the veterans elevated lipids. The Board finds that the VA clinical opinion, which is based on a review of the Veteran's STRs, and post service clinical records, and provides a rationale which is specific to the Veteran is more probative than the general information websites. The Veteran may sincerely believe that he has a cardiac disability which is due to, or chronically aggravated, by medication which he takes for his service-connected disabilities. The Board finds, however, that the effect of NSAIDs on cardiac disabilities falls outside the realm of common knowledge of a lay person. Based on the foregoing, the Board finds that the Veteran's opinion does not constitute competent medical evidence and lacks probative value. see Kahana v. Shinseki, 24 Vet.App. 428, 435 (2011),. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007. Based on the foregoing, the Board finds that the preponderance of the evidence is against a grant of service connection on a secondary basis because the second criterion for service connection on a secondary basis has not been met. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Gastrointestinal disability Direct Incurrence basis The Veteran contends that he has a current chronic gastrointestinal disability due to service. The Veteran's STRs reflect that on various occasions, he had gastrointestinal complaints. An April 1962 STR reflects a diagnosis of gastroenteritis. April 1963 treatment records reflect that the Veteran sought treatment for abdominal pain, with an onset of 30 hours earlier. The treatment records show a diagnosis of acute viral gastritis. A February 1968 STR reflects that the Veteran sought treatment for epigastic pain. The impression was esophagitis versus peptic ulcer. A follow-up entry the next day reflects that the Veteran was given medication for one week. A January 1976 STR reflects that the Veteran described the onset of dull, achy pain in the right lower parasternal area. He reported that it increased in severity with inspiration. He had pain on palpation. The impression was reflux esophagitis. A November 1979 treatment record notes that the Veteran was seen for complaints of a chronic "touchy stomach" for the past three years. The Veteran described a churning feeling in the epigastic region soon followed by severe diarrhea and pain while evacuating. He reported at least one day of diarrhea each week, controlled with Kaopectate. An August 1980 SR reflects that the Veteran had complaints of severe abdominal pain and diarrhea and vomiting since "0200 last [night]. He was diagnosed with gastroenteritis. A June 1981 treatment record reflects that the Veteran had stomach cramps and diarrhea for three days. He was diagnosed with gastroenteritis. A January 1981 entry on a Special Duty Medical Abstract reflects that the Veteran had gastroenteritis and was on medication. Subsequent entries in 1982 and 1983 are negative for any suspension of special duties due to gastroenteritis, but do note that the Veteran had the flu in December 1982 and was on antihistamine medication in 1983. October 1981 STRs (to include a gastroenterology consultation sheet) reflect that the Veteran had an 18 month history of intermittent watery diarrhea and abdominal cramping. He reported that he had recently had an exacerbation of diarrhea. The impressions were possible infection, possible spastic colon, and chronic diarrhea. November 1981 STRs reflect that the Veteran was seen for a follow-up for chronic diarrhea. There was a finding of "no evidence of [irritable bowel disease.]." An April 1982 STR reflects that the Veteran had complaints of several abdominal cramping for two hours and diarrhea. He was diagnosed with gastroenteritis. A June 14, 1984 narrative summary (clinical resume) reflects that the Veteran had cholelithiasis. The Veteran denied any symptoms of acid reflux. Gastroenteritis is an acute inflammation of the lining of the stomach and intestines, characterized by anorexia, nausea, diarrhea, abdominal pain, and weakness, which has various causes, including food poisoning, consumption of irritating food or drink, or psychological factors such as anger, stress, and fear. DORLAND'S ILLUSTRATED MEDICAL DICTIONARY (31st Ed. 2007), The Veteran separated from service in July 1984. His February 1984 report of medical examination for retirement purposes reflects that his pertinent systems were normal. His February 1984 report of medical history for retirement purposes reflects that the Veteran reported that he had, or had previously had, frequent indigestion, and "stomach liver, or intestinal trouble." Correspondence from the Medical Consultants Group, dated in July 1985, reflects that the Veteran had an upper G.I. endoscopy by [T.H.] which showed only mild duodenitis. A January 1990 private medical record shows that upper gastrointestinal imaging showed findings of antral gastritis and duodenitis. No hiatal hernia or reflux was seen. March 1996 records from St. Vincent's Medical Center reflect that the Veteran had moderate chronic active non-specific gastritis; microorganisms consistent with helicobacter pylori. He also had changes consistent with reflux effect. The diagnoses noted in the March 1996 Gastro-intestinal follow up were Reflux, hiatal hernia, gastritis, and gastritis, helicobacter pylori positive. An October 1998 progress note from Dr. A.H. reflects that the Veteran was started on Prilosec. It was noted that he had been given information on the "reflux regimen" in February. The Veteran reported a primary problem of central retro sterna chest pain lasting anywhere from 30 minutes to an hour and a half, which feels like "there has been a fence post shoved into his chest." He also reported a spate problem with epigastric distress. A February 1998 record from St. Vincent's Medical Center reflects that the Veteran had distal esophageal ulcerations, gastritis, and normal channel, bulb and upper and descending duodenum. A June 2002 VA examination report reflects that the Veteran reported that "in 1962, he remembers having symptoms of heartburn, midepigastric pain which were "really severe" until approximately 1997." The diagnoses in 2002 were chronic, recurrent episodes of midepigastric pyrosis and pain with "EGD [esophagogastroduodenoscopy]-proven" ulcers and reflex plus gastritis and prepyloric erosive disease. Helicobacter pylori positive and treated successfully with antibiotics in 1996. He has had esophageal dilatation two times; once in 1998 and once in 1999. Chronic mediations in the form of Priolosec 20 mg per day for symptoms of GERD. Old history of treated with Helicobacter pylori, previously caused peptic ulcer disease." The examiner did not provide an opinion on the etiology of the Veteran's disabilities. A July 2011 VA examination report is of record. The report reflects a diagnosis of GERD. The examiner opined that the GERD was less likely as not related to the Veteran's active duty service or was otherwise related to active service. The examiner, in citing to in-service gastrointestinal-related treatment findings, commented that there was no objective evidence that the Veteran's current GERD had its onset in military service. The claims file also includes a December 2012 VA opinion. The clinician opined that the Veteran's "gastrointestinal disorders are less likely as not causally or etiologically related to his military service, caused by a service-connected disability, or worsened by a service-connected disability. The clinician's rationale was as follows: [The veteran's STRs and records] within two years of active duty are silent for hiatal hernia. Most of the Veteran's in-service GI complaints were due to gastroenteritis or viral/flu syndromes - these are acute and transient disorders that resolve with no residual and [his] retirement exam is silent for them. There was one note in the STR where the diagnosis of esopagitis was entertained however this requires objective testing to diagnose - there is no objective evidence of UGI or EGD in service. There was duodentitis found on an objective study in 1985 however this had resolved on later testing. Much of the veteran's symptomatology in service was bowel related no specific diagnosis was really ever made other than gastroenteritis. These symptoms are not prevalent in the post [active duty] private record - again there is no specific diagnosis to make a nexus to service. . . . Based on the foregoing, the Board finds that service connection for a chronic gastrointestinal disability is not warranted on a direct incurrence basis. The earliest clinical evidence of a current chronic gastrointestinal disability is more than 10 years after separation from service. The lapse of time between service separation and the earliest documentation of current disability is a factor for consideration in deciding a service connection claim. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). Moreover, there is no competent credible evidence of continuity of symptoms since service. Although the Veteran had gastrointestinal complaints in service, those symptoms were due to acute diseases or diarrhea, which is not a symptom of the Veteran's current gastrointestinal disability. The Board acknowledges the Veteran's post-service statements that he has had heartburn, and midepigastric pain in service; however, the clinical records contemporaneous to service do not reflect such chronic symptoms. In addition, the Veteran denied symptoms of acid reflux in June 1984. In addition, testing in July 1985 and January 1990 did not reflect reflux. Thus, the Board finds the Veteran less than credible with regard to onset of any current chronic gastrointestinal disability. Finally, the probative clinical opinion with regard to the etiology of the Veteran's current gastrointestinal disability is that it is not causally related to active service. The Veteran may sincerely believe that he has a gastrointestinal disability due to service, or to a service connected disability. He is competent to relate his symptoms, such as pain, an acid taste, feelings of "heartburn" and diarrhea. However, the Veteran has not been shown to possess the requisite training or credentials needed to render a competent opinion as to medical diagnosis or causation in matters of the gastrointestinal system, and as to whether such symptoms are due to virus, bacteria, or some other factors. Based on the foregoing, the Board finds that the Veteran's opinion does not constitute competent medical evidence and lacks probative value. see Kahana v. Shinseki, 24 Vet.App. 428, 435 (2011),. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer)." The Board has considered the doctrine of giving the benefit of the doubt to the appellant, under 38 U.S.C.A. § 5107 (West 2002), and 38 C.F.R. § 3.102 (2010), but does not find that the evidence is of such approximate balance as to warrant its application. Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Secondary basis In an October 2012 Written Brief Presentation, the Veteran's accredited representative contends that the Veteran may have a gastrointestinal disability related to his use of medications taken for treatment of his service-connected disabilities. The Veteran's representative specifically argued that the Veteran's use of "NSAIDS" (non-steroidal anti-inflammatory drugs) for treatment of his service-connected orthopedic-based disabilities and migraines caused the Veteran to develop gastritis, and/or GERD. The representative referred to a website on GERD and a website on side affects of NSAIDS in support of his secondary service connection assertions. (See October 2012 Written Brief Presentation.) The website cited by the accredited representative specific to gastrointestinal disorders contains general information on GERD, to include symptoms, therapy, and complications. The Science Daily website cited by the accredited representative with regard to side effects of nonsteroidal medication discussed various medications and whether it is usually recommended that they not be used in combination with NSAIDS. As noted above, articles and treatises tend to be general in nature and tend not to relate to the specific facts in a given veteran's claim. In the present case, the websites submitted by the appellant fall into this general category. Although the websites discuss GERD, and NSAIDs and their potential side effects and interaction with other drugs, the websites do not pertain specifically to this Veteran, and the website information is are not combined with any opinion of a medical professional. The Board finds that the VA clinical opinion, discussed below, which is based on a review of the Veteran's STRs, and post service clinical records, and provides a rationale specific to this Veteran, is more probative than general information websites. The December 2012 VA record reflects the opinion of the clinician, in pertinent part, as follows:. [The Veteran's] gastrointestinal disorders are less likely as not caused by or chronically worsened by his taking NSAIDS for treatment of service-connected disabilities. . . . While there is medical literature to support the causation or aggravation of gastritis by NSAIDS, there is no objective evidence in the veterans record that this is the case for him. His records are silent for NSAID induced GI injury. I do not find any evidence that he was prescribed NSAIDs after the mid 1990's. His GI treating physicians' notes are silent for need to stop NSAIDs or that he was even taking them." The Veteran may sincerely believe that he has a gastrointestinal disability which is due to, or chronically aggravated, by medication which he takes for his service-connected disabilities. The Board finds, however, that the effect of NSAIDs on the gastrointestinal system falls outside the realm of common knowledge of a lay person. Based on the foregoing, the Board finds that the Veteran's opinion does not constitute competent medical evidence and lacks probative value. see Kahana v. Shinseki, 24 Vet.App. 428, 435 (2011). See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Based on the foregoing, the Board finds that the preponderance of the evidence is against a grant of service connection because the second criterion for service connection on a secondary basis has not been met. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). ORDER Entitlement to service connection for a chronic cardiac disability to include non-ischemic cardiomyopathy and congestive heart failure, to include as secondary to the effects of medications taken for treatment of service-connected disabilities, is denied. Entitlement to service connection for a chronic gastrointestinal disability to include gastroenteritis and gastroesophageal reflux disease, to include as secondary to the effects of medications taken for treatment of service-connected disabilities, is denied. ____________________________________________ MILO H. HAWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs