Citation Nr: 1314520 Decision Date: 05/02/13 Archive Date: 05/15/13 DOCKET NO. 08-35 141 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Honolulu, Hawaii THE ISSUES 1. Entitlement to service connection for a gastric disability. 2. Entitlement to service connection for hypertension. 3. Entitlement to service connection for a heart disability and cerebrovascular accident (CVA). 4. Entitlement to service connection for a low back disability. 5. Evaluation of bilateral hearing loss disability, rated as 0 percent disabling prior to October 8, 2008. 6. Evaluation of bilateral hearing loss disability, currently rated as 10 percent disabling. REPRESENTATION Appellant represented by: Vietnam Veterans of America ATTORNEY FOR THE BOARD Rebecca Feinberg, Counsel INTRODUCTION The Veteran had active service from December 1973 to December 1976. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Honolulu, Hawaii Department of Veterans Affairs (VA) Regional Office (RO). The Veteran's claims were previously before the Board and remanded in January 2012. With regard to the claims decided herein, adequate VA examinations were conducted with respect to the claims of entitlement to service connection for a back disability and entitlement to service connection for hypertension. Therefore, as to these issues and the intertwined issue of entitlement to service connection for a heart disability, the remand directives were complied with, and the Board may proceed in adjudicating the claims. Stegall v. West, 11 Vet. App. 268 (1998). The Board has reviewed the Veteran's virtual claims file, which contains evidence that is irrelevant to the claims decided herein or duplicative of evidence already in the physical claims file. The issues of entitlement to service connection for a gastric disability and entitlement to evaluations in excess of that currently assigned for bilateral hearing loss disability 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. Hypertension did not manifest in service, is unrelated to service and was not manifested within one year of separation from service. 2. The Veteran has been shown to have several heart/cardiovascular/cerebrovascular disorders, diagnosed as history of cerebrovascular accident, mildly enlarged left atrium, symptomatic second-degree atrioventricular block, atherosclerosis and congestive heart failure, that did not manifest in service and are unrelated to service. 3. Arteriosclerosis, cardiovascular-renal disease, brain thrombosis or hemorrhage and endocarditis were not shown in service or within one year of separation. 4. Degenerative joint disease of the lumbar spine was not manifest in service or within one year of separation. Arthritis is not attributable to service. CONCLUSIONS OF LAW 1. Hypertension was not incurred in or aggravated by service, nor may it be presumed to have been so incurred. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 2. A heart disability and CVA were not incurred in or aggravated by service, and atherosclerosis, cardiovascular-renal disease, brain hemorrhage/thrombosis and endocarditis may not be presumed to have been so incurred. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 3. A low back disability, diagnosed as degenerative joint disease of the lumbar spine, was not incurred in or aggravated by service, and arthritis may not be presumed to have been so incurred. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record: (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). VCAA notice should be provided prior to an initial unfavorable RO decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In addition, the notice requirements of the VCAA apply to all elements of a service-connection claim, including: (1) Veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. This notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 486 (2006). The Veteran was provided all required VCAA notice in an August 2006 letter, prior to the initial adjudication of the claims in July 2007. The VCAA also requires VA to make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claims for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claims. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The record reflects that all pertinent available service treatment records (STRs) and all available post-service medical evidence identified by the Veteran relative to the claims decided herein have been obtained. The Veteran's written statements are also of record. Neither the Veteran nor his representative has identified any outstanding evidence that could be obtained to substantiate the claims; the Board is also unaware of any such evidence. In addition, the Veteran was afforded an appropriate VA examination in connection with his claims of entitlement to service connection for hypertension, a heart disability, and a low back disability. The Board finds that the examinations were adequate, in that they were conducted by a medical professional who reviewed the claims file, solicited history from the Veteran, and performed a thorough examination. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (noting that even if not statutorily obligated to do so, if VA provides the veteran with an examination in a service connection claim, the examination must be adequate); Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). In sum, the Board finds that VA has complied with its duty to assist the Veteran. Based on the foregoing, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. Bernard v. Brown, 4 Vet. App. 384 (1993). II. Analysis A. Service Connection Applicable Law and Regulations As an initial matter, the Board notes that record does not reflect, and the Veteran does not contend that he engaged in combat with the enemy. Therefore, the provisions of 38 U.S.C.A. § 1154(b) are not applicable. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303(a) (2012). To establish a right to compensation for a present disability, a Veteran must show: (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-the so-called "nexus" requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). The absence of any one element will result in denial of service connection. Coburn v. Nicholson, 19 Vet. App. 427, 431 (2006). Service connection may be granted for any disease initially diagnosed after service 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). 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 cardiovascular-renal disease (including hypertension), arthritis, endocarditis, brain thrombosis or hemorrhage, and arteriosclerosis, are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.307, 3.309. For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. As cardiovascular-renal disease (including hypertension), arthritis, endocarditis, brain thrombosis or hemorrhage and arteriosclerosis are considered to be chronic diseases for VA compensation purposes, if chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. §§ 3.303(b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection is also warranted for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Such secondary service connection is warranted for any increase in severity of a nonservice-connected disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(b). In addition, VA laws and regulations provide that, if a Veteran was exposed to Agent Orange during service, certain listed diseases are presumptively service-connected. 38 U.S.C.A. § 1116(a)(1); 38 C.F.R. § 3.309(e). In an August 2006 written statement, the Veteran indicated that he was not stationed in Vietnam but was indirectly exposed to Agent Orange by receiving and processing equipment returning from Vietnam. A March 2007 response from the National Personnel Records Center shows that there was no record of the Veteran having been exposed to herbicides. A separate report shows that he had no service in Vietnam. Since the Veteran has not contended that he served in Vietnam between January 9, 1962 and May 7, 1975, and the evidence shows that he never had such service, he is not presumed to have been exposed during such service to Agent Orange. 38 U.S.C.A. § 1116(f); 38 C.F.R. § 3.307(a)(6)(iii). Therefore, presumptive service connection under 38 C.F.R. § 3.309(e) cannot be awarded. However, that does not preclude the Veteran from establishing service connection on another basis, as will be discussed below. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits. VA shall consider all information and lay and medical evidence of record in a case and when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). Hypertension On a December 1973 service report of medical history, the Veteran reported a history of high or low blood pressure. A notation indicated that he had elevated blood pressure when trying to enlist before. His blood pressure was 136/88. Blood pressure readings documented during service were 150/90 in May 1975 and 126/80 in March 1976. The November 1976 separation examination shows that the Veteran's vascular system was normal, and his blood pressure was 122/84. At that time, the Veteran indicated that he did not know if he had high or low blood pressure. No other notations were given. November 1979 private treatment records contain a notation of hypertension. A March 1986 report of a private examination shows that the Veteran's blood pressure was 138/80. His vascular system was normal, and no indication of hypertension was noted. A March 1989 private treatment record contains hypertension as a problem. A July 1997 report of a private examination shows that all of the Veteran's body systems were normal. A January 2006 private record contains a diagnosis of hypertension. In April 2012, the Veteran underwent VA examination. A diagnosis of hypertension was noted to have been first given in 1979. The Veteran's claims file was reviewed, and the medical evidence was accurately noted in the examination report. Following examination, the examiner opined that hypertension was less likely than not incurred in or caused by service. The examiner reasoned that possible elevated blood pressure was noted upon the Veteran's enlistment into service. This improved with weight loss. During service, he had normal blood pressure measurements. It was not until 1979, when the Veteran was in the reserve service that he was diagnosed as having hypertension. Therefore, hypertension was less likely than not incurred in or caused by service. Based on this evidence, the Board finds that service connection for hypertension must be denied. While there was a notation at the Veteran's entry into service that he reported a history of high or low blood pressure, examination of his vascular system was normal. Therefore, he is presumed to have been sound at the time he entered service. 38 U.S.C.A. § 1111; 38 C.F.R. § 3.304(b). The Board finds that his one assertion that he had a history of high or low blood pressure does not constitute clear and unmistakable evidence that hypertension existed prior to service and was not aggravated by service, and the presumption of soundness is not rebutted. VAOPGCPREC 3-03 (July 16, 2003); Cotant v. West, 17 Vet. App. 116, 131 (2003). Neither hypertension nor manifestations sufficient to identify the disease entity are shown during service. Rather, there was one reading of 150/90 followed by a reading of 126/80 and 122/84 at separation. No competent evidence has established that a single, potentially elevated, reading is a characteristic manifestation of hypertension. Therefore, while currently-diagnosed hypertension is a chronic disease under 38 C.F.R. § 3.309(a), no notations of the disease or any characteristic manifestations of hypertension were noted in the service records. A notation of hypertension was first given in November 1979, which is more than one year following the Veteran's separation from active service. As such, service connection under 38 C.F.R. § 3.303(b) is not warranted and hypertension may not be presumed to have been incurred therein. 38 U.S.C.A. § 1101; 38 C.F.R. §§ 3.307, 3.309. Furthermore, under 38 C.F.R. § 3.303(a), service connection for hypertension also may not be awarded. Although he has not advanced a clear assertion, the Veteran contends that his hypertension is due to service. He has presented general arguments that he was exposed to herbicides when he cleaned weapons that were returned from Vietnam and has alleged that a number of his disabilities are due to this exposure. While veterans are certainly competent to provide opinions as to etiology in many cases, see Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007), the Board finds that the opinion provided by the April 2012 VA examiner is more probative than the Veteran's very general assertions. The examiner has medical training, experience, and education. He reviewed the claims file and provided reasoning for his opinion that is supported by the record. The opinion addressed the Veteran's report of a history of high or low blood pressure at entry into service and determined that the disease did not manifest until more than one year after separation. His elevated blood pressure readings decreased when he lost weight and, during service, his measurements were normal. The examiner provided a reasoned opinion as to why the Veteran's hypertension was not incurred in or aggravated by service. This is the most probative evidence of record on this matter. In the January 2013 written statement, the Veteran's representative alleges that the Veteran's diagnosis of hypertension was potentially given during a period that he was serving on inactive duty for training (INACDUTRA). He noted that the Veteran's personnel records reflect that he earned points for November 1979, showing that he was on INACDUTRA for at least part of that month during which he was first noted to have a diagnosis of hypertension. The representative also noted that the Veteran's personnel files show that he was on active duty for training (ACDUTRA) for two weeks in July 1979. Active military, naval, or air service includes any period of ACDUTRA during which the individual concerned was disabled or died from a disease or injury incurred in or aggravated in line of duty, or any period of INACDUTRA during which the individual concerned was disabled or died from injury incurred in or aggravated in line of duty. 38 U.S.C.A. § 101(21), (24) (West 2002); 38 C.F.R. § 3.6(a), (d) (2012). Active duty training is, inter alia, full-time duty in the Armed Forces performed by Reserves for training purposes. 38 C.F.R. § 3.6(c)(1) (2012). It follows that service connection may be granted for disability resulting from disease or injury incurred or aggravated while performing active duty training, or from injury incurred or aggravated while performing inactive duty training. 38 U.S.C.A. §§ 101(24), 106, 1131 (West 2002). As the Veteran in this case seeks service connection for hypertension, which is a disease, rather than injury, he is not eligible for service connection on the basis of his INACDUTRA. 38 U.S.C.A. §§ 101(24), 106, 1131. Furthermore, to the extent that he had service during July 1979, which may have been ACDUTRA or INACDUTRA, there is no allegation or lay or medical evidence to suggest that hypertension was first diagnosed or manifested during this time period, and the provisions of 38 C.F.R. § 3.307(a)(3), which allow for presumptive service connection if hypertension is manifest to a compensable degree within one year of separation from wartime service, do not apply to this period of ACDUTRA or INACDUTRA. Therefore, service connection for hypertension on the basis of a period of ACDUTRA or INACDUTRA is not warranted. As such, the evidence preponderates against a finding that service connection is warranted for hypertension, and the claim must be denied. Heart Disability and CVA On a December 1973 service report of medical history, the Veteran denied pain or pressure in his chest or any other related symptoms. The November 1976 separation examination shows that the Veteran's heart was normal. At that time, he denied a history of shortness of breath, pain or pressure in his chest, or other heart trouble. A March 1986 report of a private examination shows that the Veteran's heart was normal. A March 1986 private treatment record shows that the Veteran reported shortness of breath and chest pain. He also noted trouble with his back when bending down. A March 1989 private treatment record shows that the Veteran denied a history of any heart problems. An August 1995 report of a private examination shows that the Veteran denied a history of heart disease or chest pain in the past year. An August 1995 private record indicates that the Veteran complained of occasional chest pain that lasted for a few minutes. An August 1996 private examination report shows that the Veteran's heart was normal. A July 1997 report of a private examination shows that all of the Veteran's body systems were normal. A January 2006 private record contains an impression of mild, concentric left ventricular hypertrophy. January 2006 private hospitalization records shows that the Veteran incurred an ischemic stroke with right-sided face and right extremity numbness with preserved motor function. A May 2006 private treatment record shows that the Veteran had a history of a stroke. An August 2006 private treatment record shows that the Veteran complained of chest pain that had been present for a few days. He had a history of a cardiovascular accident and complained of weakness to the left arm. A private report of an October 2006 chest x-ray shows that the heart and lungs were normal. A May 2007 VA treatment record shows that the Veteran underwent carotid duplex ultrasound, which revealed a non-hemodynamically significant atherosclerotic plaque deposition. A June 2007 private report of a chest x-ray revealed atherosclerotic calcifications of the aorta. A February 2008 private medical record shows that the Veteran underwent echocardiogram, which revealed that his left atrium was mildly enlarged. No other disabilities were found. A March 2008 private report of a carotid duplex ultrasound revealed that there was non-hemodynamically significant atherosclerotic carotid arterial stenosis. A May 2010 private treatment record shows that the Veteran had a diagnosis of symptomatic second-degree atrioventricular block and underwent permanent pacemaker implant. A January 2011 VA treatment record shows that the Veteran had a diagnosis of congestive heart failure. He also had atypical chest pain. A chest x-ray showed no acute pulmonary process. In reviewing the record, the Board finds that there are post-service diagnoses related to the heart and the Veteran's previous CVA. Some of these include a history of vascular accident, atherosclerotic plaque deposition, atherosclerotic calcifications of the aorta, mildly enlarged left atrium, non-hemodynamically significant atherosclerotic carotid arterial stenosis, symptomatic second degree atrioventricular block, and congestive heart failure. However, there is no medical or lay evidence that any of these disorders or the symptoms or manifestations thereof began during service or that atherosclerosis, cardiovascular-renal disease, brain hemorrhage, brain thrombosis, or endocarditis was manifested within one year of separation. The Veteran has not contended that this is the case, and his service medical records show that his heart examination was normal upon separation in November 1976, when he also denied a history of any symptoms associated with his heart. Atherosclerosis is "an extremely common form of arteriosclerosis, which is a thickening of an arterial wall." Zimmerman v. Principi, 4 Vet. App. 1 (1992). Therefore, it is considered a chronic disease under 38 C.F.R. § 3.309(a), along with cardiovascular-renal disease, thrombosis or brain hemorrhage, and endocarditis. However, the Veteran has not alleged that there is continuity of symptomatology related to atherosclerosis, CVA, cardiovascular-renal disease, or endocarditis since his separation from service, and there is no other evidence suggesting such continuity of any of these chronic diseases. The Veteran has alleged that he was exposed to Agent Orange during service and that this led to his current heart diagnoses. However, he has stated that he never served in Vietnam and, instead, contends that he was exposed to herbicides through weapons that were returned to his unit for cleaning. Therefore, he is not presumed to have been exposed to herbicides, and, as stated above, service connection for any claimed disability cannot be awarded under 38 C.F.R. § 3.309(e). 38 C.F.R. § 3.307(a)(6)(iii). In regard to an assertion that he was exposed because of equipment used in Vietnam, he has not established a factual foundation to establish that he had any actual exposure to herbicides. Rather, there is a mere, naked allegation of exposure of some kind. Such bare assertion does not establish actual exposure. The Veteran is certainly competent to report as to the observable symptoms he experiences, such as an onset of his cardiac symptoms, and their history. Layno v. Brown, 6 Vet. App. 465 (1994); Buchanan v. Nicholson, 451 F.3d 1331, 1337 (2006); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). However, the onset of the Veteran's symptomatology is not in question here since, as noted above, the Veteran does not allege that his symptoms or manifestations began during service. Instead, the issue is whether any currently diagnosed heart disorder is otherwise related to service. Since there are no notations related to the heart in the service treatment records, a nexus must otherwise be established between the present disability and the disease or injury in service. 38 C.F.R. § 3.303(a). The only opinion of record that potentially links any currently diagnosed heart disability to service is the Veteran's. However, the question of whether the Veteran's heart disease/CVA is related to what he contends is exposure to herbicides is a complex medical matter as to an internal medical process that is of the type that the courts have found to be beyond the competence of lay witnesses. Compare Jandreau, 492 F.3d at 1376 (lay witness capable of diagnosing dislocated shoulder); Barr, 21 Vet. App. at 308-309 (lay testimony is competent to establish the presence of varicose veins); Falzone v. Brown, 8 Vet. App. 398, 403 (1995) (lay person competent to testify to pain and visible flatness of his feet); with Clemons v. Shinseki, 23 Vet. App. 1, 6 (2009) ("It is generally the province of medical professionals to diagnose or label a mental condition, not the claimant"); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (unlike varicose veins or a dislocated shoulder, rheumatic fever is not a condition capable of lay diagnosis); Jandreau, 492 F.3d at 1377, n.4 ("sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer"). As such, the Veteran's opinion is not competent and is afforded no probative weight. There is no competent opinion of record suggesting that the Veteran's currently diagnosed heart disorders are related to service, to include alleged exposure to herbicides. While diagnosing disorders many years after separation, the Veteran's private treatment records are otherwise silent as to any reported history provided by the Veteran or notation as to the rationale for the diagnosis provided that would indicate a link to service. In the January 2013 informal hearing presentation, the Veteran's representative first refers to a theory that any of the Veteran's claimed heart disorders may be secondary to his hypertension. However, as service connection for hypertension has been denied herein, any claim of entitlement to service connection for a heart disability as secondary to hypertension is precluded by law. See Sabonis v. Brown, 6 Vet. App. 426 (1994). Considering the record in sum, the Board finds that there is no competent opinion linking any currently diagnosed heart disorder to service, nor is there any lay or medical evidence suggesting that atherosclerosis, cardiovascular-renal disease, or endocarditis was manifested in or within one year of separation from service. Therefore, the evidence in this case weighs against the Veteran's claim for service connection. As such, the benefit-of-the-doubt rule does not apply, and the claim is denied. Gilbert, 1 Vet. App. 49, 53. Low Back Disability On a December 1973 service report of medical history, the Veteran denied recurrent back pain. A March 1976 service record shows that the Veteran complained of a backache, among other symptoms. He had a twelve-hour history of low back pain with occasional radiation to his side. The impression was a viral syndrome. A subsequent March 1976 service treatment record indicates that the Veteran continued to have back aches, as well as other symptoms. An impression given that day shows an assessment of possible measles and viral syndrome. The November 1976 separation examination shows that the Veteran's spine was normal. At that time, the Veteran denied a history of recurrent back pain. An October 1982 private medical record shows that the Veteran complained of sharp pain in his low back for two days. It began when he tried to sit up in bed. The assessment was minor muscle strain. A March 1983 private record shows that the Veteran complained of back pain and was assessed as having bronchitis. A March 1986 report of a private examination shows that no notation with regard to abnormalities of the spine was given. An August 1996 private examination report shows that the Veteran's back was normal. A July 1997 report of a private examination shows that all of the Veteran's body systems were normal. A June 1997 private treatment record indicates that the Veteran complained of left-sided back pain for the last three months. No diagnosis was given after evaluation, but the Veteran was referred to physical therapy. A January 2007 private treatment record shows that the Veteran complained of back pain that started two days ago. There was no trauma. It seemed to be left-sided. Following evaluation, the impression was backache, not otherwise specified. A June 2007 VA outpatient treatment record shows that the Veteran complained of chronic intermittent low back pain with stiffness at the left low back. He reported a distant injury while in service in 1975, when he was involved in a fall. The assessment was low back pain with a likely mechanical etiology. A July 2007 VA report of an x-ray revealed mild degenerative changes of the lumbar spine manifested as lateral osteophytes. In an August 2007 written statement, the Veteran described falling down three stairs with his full pack on his back. About four days to a week later, he began to feel numbness in his mid-back and down to his lower lumbar back. He continued to have chronic low back pain until the present. In April 2012, the Veteran underwent VA examination. The diagnosis was degenerative joint disease of the lumbar spine. His medical records, to include his service treatment records, were reviewed and accurately detailed. Prior x-rays revealed mild degenerative changes of the lumbar spine. Following examination, the examiner opined that the lumbar spine disability was less likely than not incurred in or caused by service. With regard to a rationale, the examiner noted that a review of the claims file revealed complaints of back pain during service that were associated with diagnoses of viral illnesses. Medical literature shows that muscle aches are common complaints with viral illnesses. There is no evidence in the service treatment records of significant back injuries or complaints, such as a fall. The separation examination noted no back complaints and a normal examination. As there is no evidence of a fall or other significant back injury, the current back condition could not be attributed to service. After reviewing the evidence of record, the Board concludes that service connection is not warranted for a back disability. The diagnosis of degenerative joint disease of the lumbar spine has been assessed. However, for the following reasons, the Board finds that the evidence preponderates against a finding that the back disability began in or is due to or aggravated by service. In regard to the Veteran's claim of degenerative joint disease of the lumbar spine beginning in service, the Board finds that such a diagnosis was not established or "noted." To determine that a chronic disease was "shown in service," the disease identity must be established and the diagnosis not subject to legitimate question. 38 C.F.R. § 3.303(b); Walker, supra. There are notations of back pain contained in the Veteran's service treatment records, but they were attributed to viral infections. Therefore, chronicity may be legitimately questioned. The record taken as a whole weighs against the finding of a showing of a resulting chronic disease during service. These isolated complaints of back pain are attributed to viral syndromes. In the absence of notations during service that suggest manifestations sufficient to identify the disease entity, service connection under 38 C.F.R. § 3.303(b) may not be awarded. With regard to determining whether the claim may be granted under 38 C.F.R. § 3.303(a), the Board acknowledges the Veteran's contentions that he injured his back during service and has experienced symptomatology since that time. The Veteran is certainly competent to report as to the observable symptoms he experiences, such as an onset of his symptoms, and their history. Layno v. Brown, 6 Vet. App. 465 (1994). To the extent the Veteran asserts that his currently-diagnosed degenerative joint disease began when he injured his back during service, the Board finds that his statements are not credible. The Veteran did not allege that he had back pain since an injury during service until August 2007. Prior to that, the Veteran's November 1976 separation examination shows that his spine and other musculoskeletal systems were normal, and he denied any medical history of recurrent back pain. This document is a signed, sworn statement completed by the Veteran at the time of his separation examination and is highly probative evidence on the question of whether he was experiencing symptomatology or had a history of recurrent back pain at that time. His contemporaneous statement during service is far more probative than an after-the-fact allegation made in support of a claim for monetary benefits (self interest). Furthermore, when the Veteran was seen by medical professionals for complaints of back pain after service, he repeatedly reported histories of symptomatology that dated the onset to after separation. In October 1982, the Veteran reported a two-day history of such pain, in June 1997, he reported a three-month history, and in January 2007, the Veteran reported a two-day history with no history of trauma. These statements, made to medical providers at the time the Veteran is seeking treatment, are highly probative evidence. It is expected that someone seeking initial treatment would tend to provide an accurate history so as to obtain appropriate care. It was not until June 2007 that the Veteran reported a distant injury to his back during service. As such, with regard to the Veteran's allegations both that he injured his back during service and that his symptoms have continued since that time, the Board finds that the Veteran is not a credible historian. The credible evidence of record, consisting of several contemporaneous medical records and statements by the Veteran, show that his back pain occurred intermittently following separation and did not become constant until approximately 2007. While the Veteran complained of back pain during service, it was attributed to viral infections, and there is no competent and credible evidence that he manifested degenerative joint disease of the lumbar spine during service. As such, the Board finds that the Veteran cannot satisfy this necessary element to qualify for entitlement to compensation on this basis, and his claim on this theory of entitlement is denied. Likewise, there is no competent and credible evidence of record showing the manifestation of degenerative joint disease of the lumbar spine to a compensable degree within one year of separation from service. Thus, service connection is not warranted on a presumptive basis. Furthermore, in April 2012, a VA examiner provided a competent and adequate opinion on the question of whether the Veteran's currently diagnosed degenerative joint disease of the lumbar spine is related to his service. Given the absence of medical evidence of an in-service injury and subsequent continuous symptomatology and the non-credible lay statements provided by the Veteran on this basis, the examiner correctly concluded that there was no evidence of an in-service injury or abnormality during service. The opinion provided by the April 2012 VA examiner is highly probative and is afforded more weight than the Veteran's statements, which have been deemed non-credible. In any case, the examiner is shown to have medical training and knowledge that renders his opinion more probative than the Veteran's. He also provided a rationale based upon the credible evidence of record. Considering the record in sum, the Board finds that evidence in this case weighs against the Veteran's claim for service connection for a back disorder, diagnosed as degenerative joint disease of the lumbar spine. As such, the benefit-of-the-doubt rule does not apply, and the claim is denied. Gilbert, 1 Vet. App. 49, 53. ORDER Service connection for hypertension is denied. Service connection for a heart disability and CVA is denied. Service connection for a low back disability is denied. REMAND The Board finds that further development is necessary prior to adjudication of the claim remaining on appeal as to a gastric disability and bilateral hearing loss disability. When VA affords the Veteran a VA examination regarding his claim, it has a duty to ensure that the examination is adequate. In this case, the Veteran underwent VA examination in April 2012, at which time gastroesophageal reflux disease (GERD) was diagnosed and was determined to be less likely incurred in or caused by service. However, there are several issues with this examination report that cause it to be inadequate. First, the examiner asserted in discussing the rationale for the opinion given that a gastric condition was noted upon entry, but there was no documentation of continuing treatment during service. However, the Veteran's December 1973 entrance examination is normal for his abdomen and viscera and anus and rectum, and the Veteran denied a history of all related symptomatology at that time. Furthermore, the examiner failed to discuss a May 1975 service treatment record showing that the Veteran complained of blood in his bowel movements. Second, the Veteran's medical records show that, during the appeal period, he has also been diagnosed as having abdominal distention, esophagitis, mild chronic gastritis, ulcers in the duodenum, and duodenitis. The Veteran's claim was one for a gastric condition, that the Board interprets to include all related diagnoses reasonably raised by the record. This includes these diagnoses given during the appeal period, and an examination must address these to be adequate. For these reasons, the Board finds that a remand is necessary to obtain an opinion that addresses these matters. With regard to the bilateral hearing loss disability, in the January 2012 remand, the Board directed that the AMC was to contact the audiologist who conducted February 2007, October 2008, and May 2010 examinations to determine whether the Maryland CNC word test was used and to provide numerical values for the pure tone thresholds that were reported on charts. The AMC did not do this or request a release from the Veteran as to this matter. As directed in the previous remand, this must be accomplished. Stegall v. West, 11 Vet. App. 268 (1998). Accordingly, the case is REMANDED for the following action: 1. Request clarification from D.T., the audiologist that conducted the February 2007, October 2008, and May 2010 examinations. Ask whether the speech recognition scores were determined using the Maryland CNC list or another list. Also, request that numerical values be provided for the pure tone thresholds, in decibels, at each of the frequencies 1000, 2000, 3000, and 4000 Hertz, as well as the average of these scores from the above examinations. 2. Return the Veteran's claims file to the examiner that conducted the April 2012 VA examination or to another competent provider. The examiner is asked to provide opinions to the following: a. Is it clear and unmistakable (i.e., obvious, manifest, or undebatable) that the Veteran had a gastric disorder prior to his entry onto active duty in December 1973? b. If so, on the basis of all the evidence of record pertaining to the manifestations of the Veteran's gastric disorder prior to, during, and subsequent to service, is it clear and unmistakable that the Veteran's preexisting gastric disorder either (1) underwent no increase in disability during either period of service, or (2) that any increase in disability during either period of service was due to the natural progression of the condition? c. Is it as least as likely as not that any current gastric disorder is causally related to any incident of the Veteran's service or to aggravation of any preservice gastric disorder during service? The examiner is asked to address all diagnoses given in the record since he filed his claim in July 2006, which includes GERD, abdominal distention, esophagitis, mild chronic gastritis, ulcers in the duodenum, and duodenitis. A complete rationale for all opinions must be provided. 3. Readjudicate the claim of entitlement to service connection for a gastric disability. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ H. N. SCHWARTZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs