Citation Nr: 1313093 Decision Date: 04/19/13 Archive Date: 05/02/13 DOCKET NO. 10-44 649 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Paul, Minnesota THE ISSUES 1. Whether new and material evidence to reopen a claim of entitlement to service connection for tachycardia has been received. 2. Whether new and material evidence to reopen a claim of entitlement to service connection for hypertension has been received. 3. Whether new and material evidence to reopen a claim of entitlement to service connection for an anxiety disorder has been received. 4. Whether new and material evidence to reopen a claim of entitlement to service connection for diabetes mellitus has been received. 5. Entitlement to service connection for diabetes mellitus. 6. Entitlement to service connection for an acquired psychiatric disorder, to include bipolar disorder, anxiety disorder, posttraumatic stress disorder (PTSD), obsessive compulsive disorder, panic disorder, depressive disorder, and personality disorder. 7. Entitlement to service connection for erectile dysfunction, to include as secondary to a service-connected psychiatric disorder. 8. Entitlement to service connection for irritable bowel syndrome (IBS), to include as secondary to a service-connected psychiatric disorder. 9. Entitlement to service connection for a sleep disorder, to include as secondary to a service-connected psychiatric disorder. 10. Entitlement to service connection for a gastrointestinal disorder, to include as secondary to a service-connected psychiatric disorder. REPRESENTATION Appellant represented by: John S. Berry, Attorney ATTORNEY FOR THE BOARD S. Mishalanie, Counsel INTRODUCTION The Veteran served on active duty from August 1980 to September 1985. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions by the Department of Veterans Affairs (VA) Regional Office in St. Paul, Minnesota. The Board notes that, in addition to the paper claims file, there is a Virtual VA electronic claims file associated with the Veteran's claim. A review of the Virtual VA file reveals no additional records pertinent to the issues on appeal. The issues of entitlement to service connection for an acquired psychiatric disorder, erectile dysfunction, a gastrointestinal disorder, IBS, and a sleep disorder are addressed in the REMAND portion of the decision below and are REMANDED to the Department of Veterans Affairs Regional Office. FINDINGS OF FACT 1. In an April 2007 rating decision, the RO denied service connection for tachycardia because there was no evidence of chronic disability shown by the evidence of record. He was notified and did not appeal. 2. None of the new evidence associated with the claims file since the April 2007 rating decision, when considered by itself or in connection with evidence previously assembled, relates to an unestablished fact necessary to substantiate the claim for service connection for tachycardia, or raises a reasonable possibility of substantiating the claim. 3. In an April 2007 rating decision, the RO denied service connection for hypertension, diabetes mellitus, and an anxiety disorder because a nexus with service was not established. He was notified and did not appeal. 4. None of the new evidence associated with the claims file since the April 2007 rating decision, when considered by itself or in connection with evidence previously assembled, relates to an unestablished fact necessary to substantiate the claims of service connection for hypertension, or raises a reasonable possibility of substantiating the claim. 5. The evidence received since the April 2007 rating decision relates to unestablished facts and raises a reasonable possibility of substantiating the claim of service connection for an anxiety disorder. 6. The evidence received since the April 2007 rating decision relates to unestablished facts and raises a reasonable possibility of substantiating the claim of service connection for diabetes mellitus. 7. Diabetes mellitus was not manifest in service or within one year of separation, and is not shown to have developed as a result of an established event, injury, or disease during active service. CONCLUSIONS OF LAW 1. The April 2007 rating decision in which the RO denied service connection for tachycardia, hypertension, diabetes mellitus, and an anxiety disorder is final. 38 U.S.C.A. § 7105(c) (West 2002); 38 C.F.R. §§ 3.104, 20.302, 20.1103 (2012). 2. The criteria for reopening a previously denied claim of service connection for tachycardia have not been met. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156(a) (2012). 3. The criteria for reopening a previously denied claim of service connection for hypertension have not been met. 38 U.S.C.A. § 5108; 38 C.F.R. § 3.156(a). 4. The criteria for reopening a previously denied claim of service connection for an anxiety disorder have been met. 38 U.S.C.A. § 5108; 38 C.F.R. § 3.156(a). 5. The criteria for reopening a previously denied claim of service connection for diabetes mellitus have been met. 38 U.S.C.A. § 5108; 38 C.F.R. § 3.156(a). 5. Diabetes mellitus was not incurred in or aggravated by service, and may not be presumed to have been incurred therein. 38 U.S.C.A. §§ 1101, 1112, 1113, 1116, 1131, 1137 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2012), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2012), provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. They also require VA to notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. The United States Court of Appeals for Veterans Claims (Court) has held that the plain language of 38 U.S.C.A. § 5103(a) requires that notice to a claimant pursuant to the VCAA be provided "at the time" that, or "immediately after," VA receives a complete or substantially complete application for VA-administered benefits. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). The timing requirement enunciated in Pelegrini applies equally to the initial-disability-rating and effective-date elements of a service-connection claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). With respect to requests to reopen previously denied claims, a claimant must be notified of both what is needed to reopen the claim and what is needed to establish the underlying claim for service connection. See Kent v. Nicholson, 20 Vet. App. 1 (2006). In the case at hand, the record reflects that the originating agency provided the Veteran with the requisite notice by letters mailed in May 2008, February 2009, October, 2009, January 2010, and August 2010. To the extent the notice was provided after the initial adjudication of the claims, the Board notes that the claims were readjudicated most recently in a November 2010 statement of the case (SOC) and an April 2011 supplemental SOC (SSOC). Therefore, there is no prejudice to the Veteran regarding the timing of notice. The record also reflects that VA has made reasonable efforts to obtain or to assist in obtaining all relevant records pertinent to the claims herein decided. Pertinent medical evidence associated with the claims file consists of service treatment records, records from the Social Security Administration (SSA), and all identified and available post-service treatment. The Board also notes that the Veteran has been afforded multiple VA examinations and VA medical opinions. For the reasons discussed below, the Board finds that the evidence is adequate to make a determination on these claims. The Board acknowledges the Veteran was not afforded a VA examination to evaluate the etiology of his diabetes mellitus. On these facts, however, no examination is required. VA will provide a medical examination or obtain a medical opinion if the evidence indicates the existence of a current disability or persistent or recurrent symptoms of a disability that may be associated with an event, injury, or disease in service, but the record does not contain sufficient medical evidence to decide the claim. 38 U.S.C.A. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4)(i); McLendon v. Nicholson, 20 Vet. App. 79 (2006). In this case, the claim on appeal does not meet the fundamental requirement to obtain a VA medical opinion. As will be discussed below, the most probative evidence of record indicates that diabetes mellitus did not manifest in service or for many years thereafter and there is otherwise no evidence to suggest a relationship with service. For the reasons set forth above, the Board finds that VA has complied with the VCAA's notification and assistance requirements. New and Material Evidence In an April 2007 rating decision, the RO denied the Veteran's claim of entitlement to service connection for tachycardia, finding that the evidence did not show a chronic disability. The RO denied claims of service connection for hypertension and diabetes mellitus, finding that the conditions were not incurred in or otherwise related to service. The RO denied service connection for an anxiety disorder, finding that the evidence did not show a current disability or evidence of a psychiatric disorder incurred in service or within one year of separation from service. The Veteran was notified of these actions. Thereafter, he did not perfect a timely appeal. New and material evidence was also not received within the one-year appeal period. Notice of the rating decision was mailed on April 16, 2007. No evidence was received within the one-year appeal period. Because the Veteran did not timely appeal the April 2007 rating decision and new and material evidence was not received within the one-year appeal period, the decision is final. See 38 U.S.C.A. § 7105(c); 38 C.F.R. §§ 3.156(b), 20.1103. Once a decision becomes final, absent submission of new and material evidence, a claim may not thereafter be reopened or readjudicated by VA. 38 U.S.C.A. §§ 5108, 7105; 38 C.F.R. § 3.156(a); Suttman v. Brown, 5 Vet. App. 127, 135 (1993). New evidence means existing evidence not previously submitted to agency decision makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. See 38 U.S.C.A. § 5108; 38 C.F.R. § 3.156(a). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is "low." See Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). Furthermore, consideration is not limited to whether the newly submitted evidence relates specifically to the reason the claim was last denied, but instead should include whether the evidence could reasonably substantiate the claim were the claim to be reopened, either by triggering the Secretary's duty to assist or through consideration of an alternative theory of entitlement. Id. at 118. Only evidence presented since the last final denial on any basis (either upon the merits of the case, or upon a previous adjudication that no new and material evidence has been presented) will be evaluated in the context of the entire record. Evans v. Brown, 9 Vet. App. 273 (1996). In determining whether evidence is new and material the credibility of the new evidence is, preliminarily, to be presumed. If the additional evidence presents a reasonable possibility that the claim could be allowed, the claim is accordingly reopened and the ultimate credibility or weight that is accorded such evidence is ascertained as a question of fact. 38 C.F.R. § 3.156; Justus v. Principi, 3 Vet. App. 510 (1992). The evidence of record at the time of the April 2007 rating decision primarily consisted of service treatment records, VA treatment records dated from April 2001 to April 2003, private treatment records from Park Nicollet Clinic, and lay statements from the Veteran. Tachycardia Regarding tachycardia, the Veteran's service treatment records show that he was treated for episodes of tachycardia on several occasions in 1981. The working diagnosis was Wolff-Parkinson White syndrome. In October 1982, he indicated that he had not had any episodes in five months. In April 1985, he complained of tachycardia and a note was made to rule out Wolff-Parkinson White syndrome. At his August 1985 separation examination, his heart was normal; there was no murmur and he had regular rhythm. An electrocardiogram was not conducted. On his report of medical history, he was noted that he had a history of episodic tachycardia that was felt to be Wolff-Parkinson White syndrome. It was noted that he was initially treated with Inderal, but was then under no medication. Private treatment records from Park Nicollet Clinic dated from July 1987 through March 2005 and VA treatment records dated from April 2001 to April 2003 do not show any treatment for tachycardia or Wolf-Parkinson White syndrome. As noted above, in an April 2007 rating decision, the RO denied the Veteran's claim of entitlement to service connection for tachycardia because the evidence did not show a chronic disability during service or since service. The RO found that the episodes of tachycardia during service were acute and transitory and not chronic. The Board finds the evidence added to the record since the April 2007 rating decision is not new and material. The relevant evidence added to the record since the April 2007 rating decision includes VA treatment records dated from April 2003 to August 2010; the report of a January 2010 VA heart examination; private treatment records from Northpoint Health and Wellness Center, East Jefferson Hospital, Pilot City Health Center, St. Jude Medical Center; records from SSA; a September 2008 letter from a registered nurse (S.H.); lay statements from the Veteran, his mother, and a friend (S.V.). The VA and private treatment records do not show any treatment for tachycardia or Wolf-Parkinson White syndrome. In June 2007, the SSA found the Veteran disabled based solely on his mental impairments; the underlying medical records do not show any treatment for tachycardia or Wolf-Parkinson White syndrome. An August 2007 VA discharge summary indicates that he was admitted for sudden onset of right upper and lower extremity paresthesia, occipital headache, and an elevated blood pressure. An electrocardiogram (EKG), transthoracic echo, and nuclear adenosine thallium test were conducted; acute coronary syndrome was ruled out. The report of a January 2010 VA heart examination indicates that the Veteran did not have tachycardia. The EKG revealed normal sinus rhythm. The examiner indicated that she reviewed previous EKGs and that they were stable. The examiner indicated that there was no current clinical objective evidence of diagnosable cardiac disease or arrhythmia, including tachycardia. The Veteran's lay statements indicated that he had episodes of tachycardia during service, which he attributed to panic attacks. He reported that he was diagnosed with Wolf-Parkinson White syndrome and was told he only had two to three years to live. (See June 2008 statement). Lay statements from his mother and friend (S.V.) concern the Veteran's psychiatric and medical difficulties since returning from service; however, there is no mention of tachycardia or Wolf-Parkinson White syndrome. In a September 2008 statement, a registered nurse who reportedly served with the Veteran, said that the Veteran was treated for tachycardia and was told of the possibility that he had a rare form of heart disease called Wolf-Parkinson White syndrome. He said that he witnessed the Veteran hyperventilating and that his pulse was racing. He attributed the Veteran's symptoms to panic attacks. While this evidence may be considered new in the sense that it was not previously before agency decisionmakers, the evidence is not material because it does not relate to an unestablished fact necessary to substantiate the claim of service connection for tachycardia and does not raise a reasonable possibility of substantiating the claim. The new evidence does not show the existence of a chronic disability in service or currently. While the lay evidence relays that the Veteran was treated for episodes of tachycardia in service and was told he had Wolf-Parkinson White syndrome, this evidence is cumulative of the evidence of record at the time of the April 2007 rating decision. In sum, as none of the new evidence relates to any basis for the prior denial of service connection for tachycardia, the application to reopen the claim must be denied. The preponderance of evidence is against the claim, and there is no doubt to be resolved. Hypertension VA regulations provide that the term hypertension means that the diastolic blood pressure is predominantly 90 mm. or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160 mm. or greater with a diastolic blood pressure of less than 90 mm. See 38 C.F.R. § 4.104, Diagnostic Code 7101, Note (1) (2012). The Veteran's service treatment records do not show any treatment or diagnosis of hypertension. As noted above, the Veteran was treated for episodes of tachycardia. In February 1981, it was noted that his blood pressure was stable during an episode of tachycardia and ranged from 128/90 to 144/100. In March 1981, during a cardiology consultation, his blood pressure was 140/90. Later that month, his blood pressure in a supine position was 120/90 and in a standing position was 120/80. In June 1981, his blood pressure was 128/82. During an episode of tachycardia in October 1981, his blood pressure was 154/96. In November 1981, it ranged from 130/90 to 140/110. At his separation examination in August 1985, his blood pressure was 124/76 (sitting), 122/80 (recumbent), and 114/76 (standing). On the report of medical history, he denied having or having ever had high or low blood pressure. Private treatment records from Park Nicollet Clinic indicate that the Veteran's blood pressure was 118/82 in January 2004. It was noted that he was obese and had diabetes and hypercholesterolemia. A July 2004 record notes a diagnosis of hypertension; the Veteran's blood pressure was 140/100. The physician noted that the Veteran had a history of elevated blood pressure each time he was seen by him. A diagnosis of hypertension was discussed with the Veteran and the need for blood pressure control. He was started on Lisinopril. As noted above, in an April 2007 rating decision, the RO denied the claim of service connection for hypertension based on the finding that the condition was not incurred in or otherwise related to service. The relevant evidence added to the record since the April 2007 rating decision includes VA treatment records and private medical records, which show continued treatment for hypertension. An April 2002 private treatment record from Fairview Ridges Hospital indicates that the Veteran was taking Atenolol to control his blood pressure. Although this record suggests an earlier onset of hypertension (in April 2002 instead of July 2004), it does not suggest a relationship between hypertension and the Veteran's service. Lay statements from the Veteran's mother and friend (S.V.) note the Veteran's psychiatric and physical problems since returning from service but do not discuss a relationship between hypertension and his service. Likewise a statement from a registered nurse (S.H.), who reportedly served with the Veteran, does not discuss the Veteran's hypertension. In October 2010, the Veteran submitted a statement in support of his claims. Specific to hypertension, the Veteran asserted that he had high blood pressure during service with tachycardia. He submitted a duplicate copy of a February 1981 record and asserted that it showed his blood pressure was 207/96. A review of the original record, however, indicates that these findings were related to his pulse rate and not his blood pressure. At 12:07 pm, his pulse rate was 96 beats per minute. He also submitted duplicate copies of service treatment records showing that his blood pressure was 154/96 in October 1981 and 140/110 in November 1981. To the extent he asserts that the blood pressure readings in service constitute evidence of hypertension, the Board finds that these statements are cumulative and redundant of the evidence of record at the time of the April 2007 rating decision. The Veteran's blood pressure readings in service were of record and considered by the RO at the time of the April 2007 rating decision. In sum, while some of the evidence may be considered new in the sense that it was not previously before agency decisionmakers, the evidence is not material because it does not relate to an unestablished fact necessary to substantiate the claim of service connection for hypertension and does not raise a reasonable possibility of substantiating the claim. The new evidence does not show the existence of a nexus with service. As none of the new evidence relates to any basis for the prior denial of service connection for hypertension, the application to reopen the claim must be denied. The preponderance of evidence is against the claim, and there is no doubt to be resolved. Anxiety Disorder Regarding an anxiety disorder, the evidence shows that the Veteran was treated for episodes of tachycardia during service. In March 1981, he was given Inderal (a beta blocker) and valium for anxiety. In November 1981, it was noted that he had sinus tachycardia and anxiety and Inderal was reinstated. However, the service treatment records do not show ongoing treatment for an anxiety disorder. At the August 1985 separation examination, the Veteran's psychiatric evaluation was normal. On the corresponding report of medical history, he denied having or having ever had depression or excessive worry, or nervous trouble of any sort. Private treatment records from Park Nicollet Clinic indicate the Veteran was treated for "complicated depression" with suicidal/homicidal ideation in August 1988. He was transferred to the psychiatric ward at Abbott-Northwestern hospital with a diagnosis of schizoaffective disorder. In a September 2006 statement, the Veteran indicated that he had been treated for anxiety and PTSD. He said that he was hospitalized in New Orleans during the first year after his discharge; however, he could not remember the name of the hospital and did not have any records. As noted above, in the April 2007 rating decision, the RO denied service connection for an anxiety disorder because the evidence did not show a current disability or evidence of a psychiatric disorder incurred in service or within one year of separation from service. The Board finds the evidence added to the record since the April 2007 rating decision is new and material. In particular, the Board finds that the April 2008 letter submitted by Dr. D.H., a VA staff psychiatrist, suggests a possible nexus between the Veteran's current psychiatric disorder and service. In addition, VA and private treatment records submitted since April 2007 show that the Veteran has a current psychiatric disorder. This evidence, relates to unestablished facts needed to establish service connection (i.e., current disability and nexus). Based upon the reasons for the prior denial, this evidence is accepted as credible and cures at least one of the prior evidentiary defects. Therefore, the Veteran's claim of service connection for an anxiety disorder is reopened. Diabetes Mellitus Regarding diabetes mellitus, the Veteran's service treatment records are unremarkable for any complaints, treatment, or diagnosis related to diabetes mellitus. At his August 1985 separation examination, his endocrine system was normal and his urinalysis was negative for sugar. On the corresponding report of medical history, he denied having or having ever had sugar or albumin in his urine. An April 2001 VA outpatient treatment record reflects the diagnosis of diabetes mellitus after the Veteran's complaints of excessive thirst, weakness, lethargy, dizziness with standing, blurred vision, and feeling in a "fog." At that time it was noted that the Veteran had never been diagnosed or tested for diabetes, but that he suspected that he might have been diabetic for the past twenty years because of episodes of fatigue and because he drank a lot of fluid. VA and private treatment records show ongoing treatment for diabetes mellitus since April 2001. In an August 2006 statement, the Veteran said that he was diagnosed as having high blood sugar in service, but that his superiors did not want him to leave the Navy and so this might have been kept out of his records. As noted above, in an April 2007 rating decision, the RO denied the claim of service connection for diabetes mellitus based on the finding that the condition was not incurred in or otherwise related to service. The Board finds the evidence added to the record since the April 2007 rating decision is new and material. In particular, the Board finds that a September 2008 letter submitted by S.H. (a registered nurse) suggests a possible nexus between the Veteran's diabetes mellitus and service. In that letter, S.H. states that he recalled discussing the Veteran's lab results with the laboratory technician and that the Veteran's blood sugar "was over 300." This evidence, relates to unestablished facts needed to establish service connection (i.e., nexus). Based upon the reasons for the prior denial, this evidence is accepted as credible and cures one of the prior evidentiary defects. Therefore, the Veteran's claim of service connection for diabetes mellitus is reopened. Service Connection for Diabetes Mellitus At the outset it is noted that the RO has adjudicated this issue on the merits as part of this appeal. As such, there is no prejudice to the appellant in proceeding to the merits of this claim. See Bernard v. Brown, 4 Vet. App. 384 (1993). Service connection is established where a particular injury or disease resulting in disability was incurred in the line of duty in active military service or, if pre-existing such service, was aggravated during service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303(a). Service connection requires 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. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Caluza v. Brown, 7 Vet. App. 498 (1995). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303(a). In addition, for veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, including diabetes mellitus, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.307, 3.309 (2012). Where there is a chronic disease shown in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). When a condition noted during service is not shown to be chronic, or the fact of chronicity in service is not adequately supported, then a showing of continuity of symptomatology after discharge is required to support the claim. 38 C.F.R. § 3.303(b); Walker v. Shinseki, __ F.3d __, No. 2011-7184, 2013 WL 628429 (Feb. 21, 2013) (noting that the continuity of symptomatology provisions apply to the chronic disorders as listed in 38 C.F.R. § 3.309(a)). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b). As noted above, the medical evidence shows that the Veteran was first diagnosed with diabetes mellitus in April 2001; however, the Veteran and S.H. assert that the Veteran was diagnosed with high blood sugar in service and that this was kept out of his records. The Board acknowledges that the Veteran is competent to report that he was told he had high blood sugar in service. Likewise, S.H. is competent to report that he had a conversation with the laboratory technician who told him that the Veteran's blood sugar was 300. As lay witnesses, they are competent to testify to their personal experiences, but these statements must be weighed against the other evidence of record. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). The Board notes that S.H. was later trained as a registered nurse; however, he was not trained as a nurse during service and did not administer the testing that reportedly showed that the Veteran had high blood sugar. Therefore, his statement is competent only insofar as it relays a conversation that he had with a laboratory technician. When considering the entire evidence of record, the Board finds the normal endocrine system findings, along with negative urinalysis, during the August 1985 separation examination are of greater probative weight than the more general lay assertions of the Veteran and S.H., even assuming those lay assertions as to diagnosis are competent. See Kahana v. Shinseki, 24 Vet. App. 428, 433, n. 4 (2011) (noting impropriety of the Board categorically discounting lay testimony and requiring the Board to determine, on a case by case basis, whether a veteran's particular disability is the type of disability for which lay evidence is competent). In addition, on the August 1985 report of medical history, the Veteran denied having or having ever had sugar in his urine. Furthermore, when he was initially diagnosed with diabetes in April 2001, he reported that he had never been diagnosed or tested for diabetes. These statements tend to weigh against his later assertions that he was found to have high blood sugar in service. The Board notes that when the Veteran was diagnosed with diabetes in April 2001, he reported that he suspected that he had diabetes for 20 years due to episodes of fatigue and increased thirst. As noted above, continuity of symptomatology can establish service connection for a chronic disability when such is shown in service; however, there must be a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. In this case, for the reasons discussed above, the most probative evidence does not indicate that diabetes mellitus manifested in service or that there was a combination of manifestations sufficient to identify the disease process. Again, the Board points to the normal endocrine system findings and negative urinalysis. In sum, the weight of the evidence indicates that the Veteran's diabetes mellitus did not manifest in service or for many years thereafter and there is otherwise no evidence to suggest a relationship with service. Given that the preponderance of the evidence is against the claim, the doctrine of reasonable doubt is not applicable to this claim. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. ORDER New and material evidence not having been received, the application to reopen a claim of service connection for tachycardia is denied. New and material evidence not having been received, the application to reopen a claim of service connection for hypertension is denied. New and material evidence having been received, the application to reopen the claim of service connection for diabetes mellitus is reopened, and, to that extent, the appeal is allowed. New and material evidence having been received, the application to reopen the claim of service connection for an anxiety disorder is reopened, and, to that extent, the appeal is allowed. Service connection for diabetes mellitus is denied. REMAND Regarding the Veteran's claimed acquired psychiatric disorder, the Board finds that further action is warranted. Specifically, the Veteran has identified private treatment records that are potentially relevant to his claim and VA has a duty to make reasonable efforts to obtain them. 38 U.S.C.A. § 5103(A); 38 C.F.R. § 3.159(c)(1). When he filed his claim, the Veteran reported that he was hospitalized shortly after service for psychiatric problems in New Orleans, but he could not remember the name of the hospital. Later, he submitted a bill from East Jefferson Hospital for ambulance services rendered in April 1987, stating that he was taken by an emergency ambulance to the hospital in New Orleans for severe panic attack and post traumatic stress problems. The Veteran also submitted an undated discharge assessment record from St. Jude Medical Center. The record notes psychiatric outpatient follow-up care. The Veteran stated that he was treated in the emergency room at St. Jude for PTSD in 1987. An August 1988 private treatment record from Park Nicollet Clinic (Park Nicollet) indicates that Veteran reported a three day history of insomnia and feelings that he wanted to murder his parents. It was noted that he had a psychiatric history and had suicidal thoughts in the past. The assessment was complicated depression with suicidal/homicidal ideation and paranoid ideation. He was transferred for admission to the psychiatric ward at Abbott-Northwestern Hospital. A discharge note from Park Nicollet indicates that the final diagnosis was schizoaffective disorder. The Veteran also submitted an undated treatment record from Northpoint Health & Wellness Center (Northpoint), which indicates that he was diagnosed with depression and an anxiety disorder. In March 2007, the RO attempted to obtain records from Northpoint, but the letter was returned from the U.S. Postal Service as undeliverable with instructions to provide a better address. There does not appear to be any further attempts by the RO to obtain a better address and the Veteran was not notified that the RO was unable to obtain these records, pursuant to 38 C.F.R. § 3.159(e). The Veteran also submitted an August 2006 record from Pilot City Health Care, which indicates that he was being referred for a mental health evaluation and would be re-evaluated in February 2007. On remand, the RO should also obtain and associate with the claims file all outstanding VA medical records. While the claims file currently includes treatment records dated through August 2010 from the VA Medical Center (VAMC) in Minneapolis, Minnesota, more recent treatment records may now be available. The Board emphasizes 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. See Dunn v. West, 11 Vet. App. 462, 466-67 (1998). As such, the RO should obtain any updated records of VA treatment, following the current procedures prescribed in 38 C.F.R. § 3.159(c) as regards requests for records from Federal facilities. Regarding the issues of entitlement to service connection for erectile dysfunction, a gastrointestinal disability, IBS, and a sleep disorder, the Veteran has argued that these disabilities are secondary to his claimed acquired psychiatric disorder. As such, the claims are inextricably intertwined and must also be remanded. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are "inextricably intertwined" when they are so closely tied together that a final Board decision on one issue cannot be rendered until the other issue has been considered). Regarding the claimed gastrointestinal disability, the Board also finds that a VA examination is necessary to decide the claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c)(4); McLendon, 20 Vet. App. at 81. The Board notes that the Veteran had episodes of gastroenteritis during service and was diagnosed with salmonella. VA outpatient treatment records reflect that the Veteran has been treated and diagnosed with gastroesophageal reflux disease (GERD). Although an October 2010 VA examiner rendered an opinion as to whether the Veteran's complained IBS was related to service, no medical opinion has been obtained with regard to his gastrointestinal complaints. Accordingly, the case is REMANDED for the following action: 1. Contact the Veteran, and, with his assistance, identify any outstanding records of pertinent medical treatment from VA or private health care providers. Specifically, request that he provide authorization forms necessary to allow the RO to attempt to obtain his private treatment records from the following providers/facilities: (a) East Jefferson Hospital, (b) St. Jude Medical Center, (c) Abbott-Northwestern Hospital, (d) Northpoint Health & Wellness Center, and (e) Pilot City Health Care. Thereafter, the RO should attempt to obtain those records and any other records identified by the Veteran. If no records can be obtained after an exhaustive search, VA's efforts and any resolution determined must be fully documented for the record, compliance with the requirements of 38 C.F.R. § 3.159(e)(i)-(iv) (2012) must be ensured. 2. The RO should obtain all outstanding, pertinent records of evaluation and/or treatment of the Veteran from the Minneapolis VAMC (dated since August 2010) or other places of appropriate treatment. The Veteran should be requested to provide information concerning any pertinent treatment. The RO must follow the procedures set forth in 38 C.F.R. § 3.159(c) as regards to requesting records from Federal facilities. All records and/or responses received should be associated with the claims file. 3. Schedule the Veteran for a VA examination to determine the etiology of any current gastrointestinal disability, to include GERD. The Veteran's claims folder should be forwarded to the examiner in conjunction with the examination. All pertinent symptomatology and findings should be reported in detail. After examination of the Veteran and review of the entire record, the examiner is requested to identify any current gastrointestinal disabilities, and provide an opinion, with complete rationale, as to whether it is at least as likely as not (50 percent or greater probability) that any current gastrointestinal disability manifested in service, is causally related to episodes of gastroenteritis and salmonella in service, or is caused or aggravated by a service-connected disability. The medical rationale for any opinion expressed must be provided. 4. After the above has been completed to the extent possible, the RO should review the record and conduct any other development as may be indicated by the responses received as a consequence of the action taken in the preceding paragraphs. This should include scheduling the Veteran for a VA examination or obtaining a supplemental opinion, if warranted. If additional development is needed, such should be accomplished. 5. Then readjudicate the claims remaining on appeal. If any benefit remains denied, the RO should issue an appropriate SSOC and provide the Veteran and his representative the opportunity to respond. The case should then be returned to the Board for further appellate review, if otherwise in order. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims 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). ______________________________________________ MICHAEL D. LYON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs