Citation Nr: 1320465 Decision Date: 06/25/13 Archive Date: 07/05/13 DOCKET NO. 05-03 646 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for chronic obstructive pulmonary disease (COPD), to include as due to in-service herbicide exposure and/or secondary to service-connected Type II diabetes mellitus and/or posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for hypertension, to include as due to in-service herbicide exposure and/or as secondary to service-connected Type II diabetes mellitus and/or posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD A. Shawkey, Counsel INTRODUCTION The Veteran had active duty service from October 1969 to January 1972, including military service in the Republic of Vietnam. Since that time, he also had military service in the Alabama Army National Guard, to include a period of active duty for training (ACDUTRA) in September 1994. This case comes before the Board of Veterans' Appeals (Board) on appeal from February 2006 and October 2006 rating decisions of the Montgomery, Alabama, Regional Office (RO) of the Department of Veterans Affairs (VA). In February 2010, the Veteran testified before an Acting Veterans Law Judge (AVLJ) of the Board at the local RO in Montgomery, Alabama (Travel Board hearing). A copy of the transcript is associated with the claims file. The AVLJ who conducted the February 2010 Board hearing has since retired. The Board sent the Veteran a letter informing him of this and indicating he could have another Board hearing with another Veterans Law Judge (VLJ) who would ultimately decide this appeal. 38 U.S.C.A. § 7107(c) (West 2002); 38 C.F.R. §§ 20.707, 20.717 (2012). The Veteran responded in a February 2012 letter that he did not want another Board hearing. Thus, the Board will decide his case based on the evidence currently of record. This matter was previously before the Board in July 2010 and August 2012 at which times the Veteran's appeal was remanded to the RO via the Appeals Management Center (AMC), in Washington, DC, for further development. Such development included sending the Veteran additional VCAA notice, verifying the Veteran's period of active duty and ACDUTRA service, requesting additional pertinent treatment records, and affording him a new VA examination in order to obtain a nexus opinion. There has been substantial compliance with the Board's remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). FINDINGS OF FACT 1. Service connection is in effect for PTSD, rated 50 percent disabling; diabetes mellitus, rated 40 percent disabling; peripheral neuropathy of both lower extremities, separately rated 20 percent disabling; tinnitus, rated 10 percent disabling; peripheral neuropathy of each upper extremity, separately rated 10 percent disabling; and residuals of a fracture of the thumb, hearing loss of the right ear, and erectile dysfunction, all rated noncompensably disabling. He has a combined 90 percent rating with special monthly compensation based on the loss of use of a creative organ. 2. The Veteran's COPD is not attributable to service or to a service connected disability. 3. The Veteran's hypertensive vascular disease is not attributable to service or to a service connected disability. CONCLUSIONS OF LAW 1. COPD was not incurred in or aggravated by service, nor is such disability proximately related to or aggravated by a service connected disability. 38 U.S.C.A. §§ 1110, 1116, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2012). 2. Hypertensive vascular disease was not incurred in or aggravated by service, may not be presumed to have been incurred in service, nor is such disability proximately related to or aggravated by a service connected disability. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1116, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Veterans Claims Assistance Act of 2000 The requirements of 38 U.S.C.A. §§ 5103 and 5103A have been met. There is no issue as to providing an appropriate application form or completeness of the application. VA notified the Veteran in November 2005 and December 2012 of the information and evidence needed to substantiate and complete a claim, to include notice of what part of that evidence is to be provided by the claimant, what part VA will attempt to obtain, and how disability ratings and effective dates are determined (see December 2012 letter). The issues were readjudicated in a March 2013 supplemental statement of the case. VA has fulfilled its duty to assist. The RO has made reasonable and appropriate efforts to assist the appellant in obtaining the evidence necessary to substantiate these claims, including requesting information from the appellant regarding pertinent medical treatment he may have received and obtaining such records, as well as affording him a VA examination during the appeal period. The Veteran was afforded a pertinent VA examination in December 2011 and an addendum opinion was rendered in December 2012. The examiner provided sufficient detail for the Board to make a decision and his reports are deemed adequate with respect to these claims. As noted, the appellant provided testimony to the Board in February 2010, and at that hearing he was provided notice of the elements pertinent to his service connection claims and ensured that all pertinent evidence was on file or would be submitted. The Veteran's contentions were discussed and are part of the transcript. Such actions supplement the VCAA and comply with 38 C.F.R. § 3.103. Hence, VA has fulfilled its duty to notify and assist the appellant, and adjudication at this juncture, without directing or accomplishing any additional notification and/or development action, poses no risk of prejudice to the appellant. See, e.g., Bernard v. Brown, 4 Vet, App. 384, 394 (1993). The appeal is now ready to be considered on the merits. II. Facts The Veteran's service treatment records do not show treatment or complaints for hypertension or COPD. Inservice examination reports reflect the following blood pressure readings: 104 (systolic)/64 (diastolic) at the December 1969 enlistment examination, 104/74 at a March 1970 flight examination, and 120/80 at the January 1972 separation examination. The January 1972 separation examination report also shows a normal clinical evaluation of the lungs and heart. A subsequent examination, in April 1972, revealed a blood pressure reading of 110/70. Chest x-rays performed at these examinations were negative/normal. In December 1975, the Veteran filed a claim for service connection for disabilities other than hypertension and COPD. A chest x-ray performed by VA in February 1976 was negative except for a calcified granuloma. A September 1990 Report of Medical History from the Army National Guard notes that the Veteran stopped smoking in August 1990. It also notes that it was at this time, in August 1990, that the Veteran was hospitalized for chest pain and underwent cardiac catherization. A laboratory report in September 1990 shows that the Veteran's glucose level was 98 with a normal range from 65 - 110. A medical screening summary report in November 1990 shows that the Veteran's fasting blood sugar was 98 mg/dl. A medical record dated in September 1994 shows that since the last periodic physical examination the Veteran had seen his physician for mild hypertension. It also shows that he was taking Zestril for mild blood pressure which he began taking four months earlier. A report completed by D. Martin, M.D., in February 1995 notes that the Veteran had a history of hypertension. An April 1995 Army National Guard examination report shows that urinalysis results were negative for sugar. The Veteran denied having diabetes on an April 1995 Army National Guard Report of Medical History. A medical screening summary report in August 1995 shows that the Veteran's fasting blood sugar was 118 mg/dl (<=115 mg/dl). Laboratory results in May 1998 show that the Veteran's glucose level was high at 118 with a reference range from 65 - 115. Army National Guard records include a May 1998 physical report noting that the Veteran had high blood pressure and diabetes mellitus. His medication included Lisinopril. On file is a letter from a private physician, Dr. Martin, dated in May 1998, to the Alabama Army National Guard noting that the Veteran had been his patient for eight years and had a history of hypertension. A medical screening report in January 1999 shows that the Veteran's fasting blood sugar was 111 mg/dl (<=115 mg/dl). A VA outpatient record in November 2001 reflects a diagnosis of hypertension and shows that the Veteran was taking medication for this disability. A computed tomography (CT) scan of the Veteran's chest in October 2003 revealed a solitary small calcified granuloma in the right lower lobe, the lungs were otherwise clear. No infiltrates or masses were seen and no cavitating lesion or significant scarring were recorded. There were also no pleural effusions. On file is an award letter from SSA awarding the Veteran disability benefits effective October 21, 2003, due to a primary diagnosis of chronic pulmonary insufficiency and a secondary diagnosis of affective/mood disorder. Records associated with that decision are also on file. In November 2003, the Veteran was admitted to a private hospital for right and left heart catherization because of exertional dyspnea. His history included smoke inhalation in 1985 and repeated exposure to diesel smoke. He was noted to have quit smoking 14 years earlier and was diagnosed as having diabetes two to three years earlier. A chest x-ray report dated in November 2003 shows likely granuloma with no infiltrates or pleural effusions. The Veteran reported at a VA general examination in November 2003 that he had limited lung capacity and was only able to walk 100 yards at a time. He said he had been exposed to a lot of smoke at his work. The examination report notes that he had COPD due mainly to toxic fumes while at work. It states that he was working as a firefighter. It also states that he had been a smoker for 12 years. X-rays were noted to show emphysematous changes. Pulmonary function tests performed in November 2003 were noted to show no airway obstruction, decreased PVC c/w trapping. Lung volumes showed mild restriction and gas trapping. Diffusion showed severe diffusion impairment. A VA PTSD examination report dated in November 2003 notes the Veteran's work history as including an ambulance worker from 1972-1976, a firefighter since 1976, and a fire investigator for five years. VA outpatient records in 2003 include problem lists that include pulmonary fibrosis of questionable etiology. They also include diabetes mellitus, type II, noted to be diagnosed in 1999 and initially treated with oral agents/diet followed by insulin in October 2003. At a VA diabetes examination in July 2004, the Veteran reported that he had not smoked for 16 years, but that he used to smoke a pack of cigarettes a day for 12 years. He also reported that he had worked as a fireman for 30 years and was retired. He was diagnosed as having diabetes mellitus, type II. The Veteran's physician, Dr. Auxier, stated in November 2004 that the Veteran was an insulin-dependent diabetic and the condition was well controlled on the current dosage of medication. A December 2004 primary care clinic note contains a problem list which includes diabetes mellitus, type II, diagnosed in 1999. This note states that the Veteran was initially treated with oral agents and diet and then insulin beginning in 2003. This record also notes that the Veteran had hypertensive vascular disease since the 1980s, pulmonary fibrosis of questionable etiology, and restrictive defect on pulmonary function testing. On file is a September 2005 letter from Dr. Morris who said the Veteran was being followed in his office for severe airflow restriction with a FEV1 (forced expiratory volume in one second) of only 33% and FEV1/FVC (forced vital capacity) of 81%. He relayed the Veteran's report that he had Agent Orange exposure in service and was requesting further evaluation regarding this. He said given the complicated nature of this, it would be appropriate. In October 2005, the Veteran filed a claim for service connection for COPD due to exposure to Agent Orange and for hypertension secondary to diabetes mellitus. On file is a May 2006 VA gastrointestinal examination report reflecting the Veteran's report of first being diagnosed as having diabetes in 1995. It also states that the Veteran was a retired fireman with pulmonary fibrosis presumed to be secondary to exposure in the past. A private pulmonary function test report in June 2008 shows FVC and FEV1 each of 45% predicted, FEV1/FVC of 98% predicted, and DLCO of 52% predicted. On file is an August 2008 "To Whom it May Concern" letter from a VA physician stating that the Veteran was unable to work due to pulmonary fibrosis complicated by restrictive lung disease. Records from Dr. Morris in 2008 and 2009 include a January 2009 record showing that the Veteran had questions about whether or not his Agent Orange exposure from Vietnam could be contributing to his respiratory problems. Dr. Morris said he told the Veteran he was uncertain about this and advised him to check with VA. These records contain impressions of severe airflow restriction, dyspnea with any type of exertional activity, chronic tachycardia and Agent Orange exposure. A January 2009 vocational rehabilitation assessment report notes that with respect to COPD, the Veteran passed out on the job in 2003 at a call and was seen for a pulmonary function test at which time he was told he could not return to work.. The report also notes that the Veteran had been on Social Security Disability Insurance (SSDI) since 2004. In December 2009, the Veteran underwent a VA unemployment examination. The date of onset of diabetes mellitus and COPD was noted to be in 1995. The Veteran said that he began to have shortness of breath and would give out easily. He said that this worsened over the years and six months earlier he began requiring oxygen all the time. The record contains a January 2010 statement from a private doctor who reported that the Veteran's diabetes mellitus affects his total body functionality. On file is a March 2010 report from Dr. Morris stating that the Veteran's diabetes contributed to his shortness of breath. The Veteran testified at a Board hearing in February 2010 that he thought his COPD was related to service and not to his postservice years as a firefighter because he was given breathing apparatus as a firefighter which protected him from exposure to toxic inhalants. He also said he was first diagnosed as having hypertension around 1995/1996 and diabetes in the 1990s. He said he thought he was diagnosed as having hypertension before being diagnosed with diabetes. He added that he smoked tobacco for about five years 30 years earlier. A VA examination report in December 2011 shows that the Veteran had hypertension since 1993. Blood pressure readings taken at the examination showed readings of 110/67, 99/65 and 106/71. The report notes that the Veteran started having issues with elevated blood pressure readings in the early to mid 1990s and was started on hypertension medication at that time. This was noted to be prior to his diabetes mellitus diagnosis. This disability was not noted to impact the Veteran's ability to work. The report also shows that the Veteran had COPD since the 1990s. It notes that he started having issues with dyspnea on exertion and wheezing in the mid 1990s and was assessed by his primary care physician as having COPD. This condition was also noted to have occurred prior to the diagnosis of diabetes mellitus. This condition was noted to have progressed to the point that the Veteran needed oxygen at night in the early 2000s and he needed oxygen on a chronic basis by the late 2000s. He was noted to have a tobacco smoking history. Pulmonary function tests performed in December 2009 were recorded as showing FEV-1 of 48% predicted, FVC of 44% predicted and DLCO of 53% predicted. The examiner reported that this disability would prevent employment of any nature due to the Veteran's chronic oxygen and dyspnea with mild exertion. After examining the Veteran and reviewing the claims file, the examiner opined that it was less likely than not that the Veteran's hypertension and COPD were incurred in or caused by service. He reasoned that the Veteran's service treatment records clearly show that he did not have hypertension or COPD in service and both of these disabilities started well after service, in the 1990s. He further reported that the service treatment records related to active duty for training clearly show that the onset of these conditions were between the training periods. He opined that hypertension was due to aging, genetics and obesity and COPD was due to the Veteran's smoking history and his prolonged exposure from his postservice occupation as a firefighter. Regarding aggravation, the examiner opined that these conditions were less likely than not proximately due to or the result of the Veteran's service-connected condition. He explained that both conditions preceded the diabetes mellitus which was very well documented. He also explained that there was no renal dysfunction to indicate that diabetes mellitus has an effect on the hypertension. He stated that there was "absolutely no correlation between control of the Veteran's blood pressure readings and his PTSD symptoms based on the review of the treatment records." The examiner further stated that the Veteran had mild to moderate hypertension prior to diabetes mellitus and still had this same degree of hypertensive disease. He opined that the current severity of the hypertension was not greater than the baseline. In written argument in May 2012, the Veteran's representative raised the possibility that the Veteran's diabetes mellitus had developed years prior to the diagnosis. He enclosed an article from the Mayo Clinic to this effect and said that it was plausible that the Veteran had diabetes unknowingly at the time he had COPD. Similarly, he said that it was plausible that the Veteran lived for years with PTSD prior to being diagnosed with the disability and enclosed an article indicating that people with PTSD have been reported to have an increased risk for hypertension. He requested that the Veteran be afforded another examination for a more reasoned opinion. In December 2012, the December 2011 VA examiner issued an addendum opinion opining that the Veteran's COPD was not related to, caused by or aggravated by his inservice exposure to herbicides or to his service connected PTSD and/or diabetes mellitus. He further opined that it was less likely as not (less than 50%) that his hypertension was related to, caused by, or aggravated by his service exposure to herbicides or to his service connected PTSD and/or diabetes mellitus. In regard to COPD, the examiner explained that for decades it has long been established that the risk factor for COPD is tobacco history and the Veteran has that risk factor. He further explained that there was no accepted link between PTSD or DM and COPD based on the peer reviewed literature. In addition, he explained that COPD is not a presumptive condition for herbicide exposure based on "IOM" research, and there is no known potential pathophysiologic connection that could even explain a cause and effect link between COPD and his service connected conditions. As for hypertension, the examiner explained that the well established risk factors for essential hypertension were advanced age, obesity and dietary factors. He said the Veteran had all of these risk factors. He also said that diabetes was a risk factor only in the presence of renal disease. He said the Veteran's most recent labs from the previous month showed completely normal renal function. As for PTSD, the examiner explained that PTSD and other psychiatric conditions cause only transient elevations in blood pressure which is not the same as the sustained and maintained elevations that are seen in essential hypertension. Lastly, the examiner reported that hypertension is not a presumptive condition for herbicide exposure based on "IOM" research. III. Analysis Law and Regulations As an initial matter, the Board notes that the Veteran is not asserting, nor does the evidence show, that his COPD or hypertension is the result of engaging in combat with the enemy. Therefore, the combat provisions of 38 U.S.C.A. § 1154(b) (West 2002) are not applicable. In general, service connection may be granted for disability or injury incurred in or aggravated by active military service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303(a). Notwithstanding the above, service connection may be granted for disability shown after service, when all of the evidence, including that pertinent to service, shows that it was incurred or aggravated in service. 38 C.F.R. § 3.303(d) (2012). Active military, naval, or air service includes any period of active duty for training (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 inactive duty training (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). ACDUTRA includes full- time duty in the Armed Forces performed by Reserves for training purposes. 38 C.F.R. § 3.6(c)(1) (2012). INACDUTRA is defined as duty other than full-time duty prescribed for Reserves or the National Guard of any state. 38 U.S.C.A. § 101(23) (West 2002);38 C.F.R. § 3.6(d) (2012). Therefore, service connection may be granted for disability resulting from disease or injury incurred or aggravated while performing ACDUTRA, or from injury incurred or aggravated while performing INACDUTRA. 38 U.S.C.A. §§ 101(24), 106, 1131 (West 2002). The definition of active duty also includes any periods of INACDUTRA during which an individual becomes disabled or dies from an acute myocardial infarction, a cardiac arrest, or a cerebrovascular accident that occurred during such training. 38 C.F.R. § 3.6 (2012). See Paulson v. Brown, 7 Vet. App. 466, 470 (1995) (if claim relates to period of ACDUTRA, a disease or injury resulting in disability must have manifested itself during that period); Biggins v. Derwinski, 1 Vet. App. 474, 478 (1991). 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." Davidson v. Shinseki, 581 F. 3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F. 3d 1163, 1167 (Fed. Cir. 2004). 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, 708 F. 3d 1331 (Fed. Cir. 2013) (noting that the continuity of symptomatology provisions apply only to listed chronic conditions). For veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic diseases, including hypertensive vascular disease, are presumed to have been incurred in service if manifested to a compensable degree within one year of separation from service. 38 U.S.C.A. §§ 1101(3), 1112(a)(1), 1113, 1137; 38 C.F.R. §§ 3.307(a), 3.309(a). Service connection may also be granted for disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Additional disability resulting from the aggravation of a nonservice-connected condition by a service-connected condition is also compensable under 38 C.F.R. § 3.310(b); Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). The Board notes that VA amended its regulation pertaining to secondary service connection, effective from October 10, 2006. See Fed. Reg. 71 Fed. Reg. 52,744 (2006) (codified at 38 C.F.R. § 3.310). The new regulation appears to place additional evidentiary burdens on claimants seeking service connection based on aggravation; specifically, in terms of establishing a baseline level of disability for the non-service-connected condition prior to the aggravation. As the Veteran's claim for service connection for COPD and hypertension was filed in October 2005, which is prior to the effective date of the amended regulation, the former version of 38 C.F.R. § 3.310 is for consideration. See 38 C.F.R. § 3.310 (pre October 10, 2006). A veteran, who, during active military service, served in Vietnam during the period beginning in January 1962 and ending in May 1975, is presumed to have been exposed to herbicides. 38 C.F.R. §§ 3.307, 3.309. If a veteran was exposed to an herbicide agent during active military, naval, or air service, the following diseases shall be service-connected even though there is no record of such disease during service: AL amyloidosis, chloracne or other acneform disease consistent with chloracne, Type 2 diabetes, Hodgkin's disease, chronic lymphocytic leukemia, multiple myeloma, non-Hodgkin's lymphoma, Parkinson's disease, acute and subacute peripheral neuropathy, porphyria cutanea tarda, prostate cancer, respiratory cancers (cancer of the lung, bronchus, larynx or trachea), and soft-tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). 38 C.F.R. § 3.309(e); 75 Fed. Reg. 53,202-53,216, 53,205 (Aug. 31, 2010). During the pendency of the appellant's claim and appeal, VA amended 38 C.F.R. § 3.309(e) to include three new disorders: ischemic heart disease, Parkinson's disease, and B cell leukemias. See 75 Fed. Reg. 53,202-53,216 (August 30, 2010). This amended rule applies to claims received by VA on or after August 31, 2010 and to claims pending before VA on that date. 75 Fed. Reg. 53202 (August 31, 2010). Note 3 under this regulation states, in part, that for purposes of this section, the term ischemic heart disease does not include hypertension. Notwithstanding the foregoing presumptions, a claimant is not precluded from establishing service connection with proof of direct causation. 38 U.S.C.A. § 1113(b); Combee v. Brown, 34 F. 3d 1039, 1042 (Fed. Cir. 1994). VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107 (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Discussion Service connection is in effect for PTSD, rated 50 percent disabling; diabetes mellitus, rated 40 percent disabling; peripheral neuropathy of both lower extremities, separately rated 20 percent disabling; tinnitus, rated 10 percent disabling; peripheral neuropathy of each upper extremity, separately rated 10 percent disabling; and residuals of a fracture of the thumb, hearing loss of the right ear, and erectile dysfunction, all rated noncompensably disabling. He has a combined 90 percent rating with special monthly compensation based on the loss of use of a creative organ. The Veteran's service treatment records do not show any complaints or treatment for COPD or hypertension. Blood pressure readings in service ranged from 104 to 120 for systolic and 64 to 80 for diastolic. Chest x-rays taken at examinations in December 1969 (enlistment) March 1970 (flight) and January 1972 (separation) were negative. The January 1972 separation examination report also shows a normal clinical evaluation of the lungs and heart. Postservice medical evidence shows that the Veteran was first diagnosed as having hypertension many years after active duty service and prior to his September 1994 active duty for training. In this regard, a medical record dated in September 1994 shows that since the last periodic physical examination, the Veteran had seen his physician for mild hypertension. It also shows that he was taking Zestril for mild blood pressure which he began taking four months earlier. As the weight of evidence does not show chronic hypertensive vascular disease since service or continuity of symptomatology after service, service connection under the provisions of 38 C.F.R. § 3.303(a) or (b) has not been established for this disability. As for COPD, the onset date of this disability is unclear, although most of the medical records relate it to the 1990s; as early as 1995 and as late as 1999. Accordingly, the provisions for establishing service connection under 38 C.F.R. §§ 3.303(a) or (b) have not likewise been shown. With respect to establishing service connection under 38 C.F.R. § 3.303(d), the evidence weighs against the Veteran's claim on both a direct and secondary basis. In this regard, the VA examiner opined in December 2011 and in an addendum in December 2012 that the Veteran's COPD and hypertension were less likely than not (less than 50% probability) proximately due to or the result of service or a service connected disability, to include by aggravation. He explained, as is noted, that neither COPD nor hypertension were shown in service or for years after. In specific regard to COPD, the examiner stated that this condition was due to the Veteran's smoking history and exposure to his postservice occupation as a firefighter. This is consistent with a VA general examination report in November 2003 stating that the Veteran had COPD due mainly to toxic fumes at work. This report also states that he had been a smoker for 12 years. The December 2011 VA examiner explained that for decades it has long been established that the risk factor for COPD is a tobacco use history and the Veteran has this risk factor. Although the Veteran testified in February 2010 that he wore fire apparatus during his 30 year employment as a firefighter and therefore was not exposed to toxic inhalants, this conflicts with his report at the VA general examination in November 2003 that he had been exposed to a lot of smoke at his work. There are also private hospital records in November 2003 showing that the Veteran had a history of smoke inhalation in 1985 and repeated exposure to diesel smoke. It further notes that he quit smoking 14 years earlier. Although the Board acknowledges that the Veteran is presumed to have been exposed to herbicides during his service in Vietnam, COPD is not one of diseases associated with herbicide exposure under 38 C.F.R. § 3.309(e). Moreover, there is no medical evidence that relates the Veteran's COPD to exposure to herbicides. See Combee, supra. Consideration has been given to Dr. Morris' September 2005 statement that the Veteran was being followed in his office for severe airflow restriction. He said the Veteran reported that he had Agent Orange exposure in service and was requesting further evaluation regarding this and that given its complicated nature, this would be appropriate. However, this statement in no way relates the Veteran's COPD to exposure to herbicides, it only indicates that further evaluation of a possible link was appropriate. Moreover, further evaluation of a possible link was considered by the VA examiner in December 2012 who rendered a negative opinion. In this regard, he stated that COPD was not a presumptive condition for herbicide exposure based on "IOM" research. He opined that the Veteran's COPD was not related to, caused by, or aggravated by his inservice exposure to herbicides. The December 2011 VA examiner also addressed the claim for COPD on a secondary basis; that is, whether COPD is secondary to the Veteran's service-connected diabetes mellitus or PTSD. He answered this question in the negative by asserting that the Veteran's COPD preceded the Veteran's diabetes mellitus. Moreover, even assuming arguendo that the Veteran's representative's assertion that the Veteran's diabetes mellitus may have preceded his COPD is true (see May 2012 Informal Hearing Presentation), the examiner nonetheless negates a link by stating that there was no known potential pathophysiologic connection that could even explain a cause and effect link between COPD and the service connected conditions. He further reported that there was no accepted link between PTSD or diabetes mellitus and COPD. He opined that the Veteran's COPD was not related to, caused by, or aggravated by his service connected PTSD or diabetes mellitus. There is no medical opinion on file that is contrary to this opinion. Similarly, the VA examiner opined that the Veteran's hypertension was not related to, caused by, or aggravated by his inservice exposure to herbicides or his service connected PTSD or diabetes mellitus. Like COPD, hypertension is not one of diseases associated with herbicide exposure under 38 C.F.R. § 3.309(e). The VA examiner noted that the Veteran's service treatment records clearly show that he did not have hypertension in service and that it developed years later, in the 1990s. He also noted that service treatment records related to active duty for training clearly show that the onset of the condition was between the training periods. He opined that the hypertension was due to aging, genetics, and obesity. In terms of the Veteran's exposure to herbicides, the VA examiner in December 2012 said that hypertension is not a presumptive condition for herbicide exposure based on "IOM" research. In terms of secondary service connection, the VA examiner explained that with respect to diabetes, the condition is only a risk factor (for hypertension) in the presence of renal disease. He pointed out that the Veteran's most recent labs from the previous month showed completely normal renal function. As for PTSD, consideration has been given to the medical articles that the Veteran's representative submitted in May 2012 regarding the effect that PTSD has on a person's physical health, including an increased risk of hypertension. The Court of Appeals for Veterans Claims has held that medical article or treatise evidence can provide important support when combined with an opinion of a medical professional. See Mattern v. West, 12 Vet. App. 222, 228 (1999) [citing Rucker v. Brown, 19 Vet. App. 67, 73-74 (1997) (holding that evidence from a scientific journal combined with doctor's statements "adequate to meet the threshold of plausibility")]. Here, there is no medical opinion that supports a link between the Veteran's PTSD and hypertension. Rather, the only medical opinion that addresses this aspect of the Veteran's claim is the VA examiner's opinion in August 2012 that negates a link. In short, the Board assigns more weight to the VA examiner's reasoned opinion which negates a link and is based on an examination of the Veteran and review of his claims finds than the medical articles which do not provide statements relevant to the facts of the Veteran's specific case. The VA examiner explained that PTSD and other psychiatric disabilities cause only transient elevations in blood pressure. He pointed out that this wasn't the same as the sustained and maintained elevations that are seen in essential hypertension. As to the Veteran's statements that his postservice COPD and hypertension are related to service or secondary to his service-connected diabetes mellitus and/or PTSD, the Veteran is certainly competent to testify as to his symptoms. See Jandreau v. Nicholson, 492 F. 3d 1372, 1376-77 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F. 3d 1331, 1336 (Fed. Cir. 2006). In addition, lay witnesses may, in some circumstances, opine on questions of diagnosis and etiology. See Davidson v. Shinseki, 581 F. 3d 1313, 1316 (Fed. Cir. 2009) (Board's categorical statement that "a valid medical opinion" was required to establish nexus, and that a layperson was "not competent" to provide testimony as to nexus because she was a layperson, conflicts with Jandreau). Notwithstanding the fact that this matter appears to be the type of medical matter as to which the courts have held lay testimony is not competent, even if the Veteran were competent to opine as to the etiology of his COPD and hypertension, the specific and reasoned opinions of the trained professional in December 2011 and December 2012 negating a nexus outweighs the Veteran's general lay assertion of a nexus. Also, as noted previously, the Veteran's assertions that he was not exposed to smoke fumes during his 30 year postservice employment as a firefighter conflicts with his report at the VA general examination in November 2003 that he had been exposed to a lot of smoke at his work. It also conflicts with private hospital records in November 2003 showing that the Veteran had a history of smoke inhalation in 1985 and repeated exposure to diesel smoke. These conflicting reports diminish the credibility of the Veteran's assertions. Based on the foregoing, the Board finds that the weight of evidence is against the Veteran's claims for service connection for COPD and hypertension, to include as due to in-service exposure to herbicides and/or secondary to service-connected diabetes mellitus and/or PTSD. In reaching this conclusion the Board has considered the applicability of the benefit of the doubt doctrine; however, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C.A. § 5107(b). ORDER Service connection for COPD, to include as due to in-service exposure to herbicides and/or secondary to service-connected diabetes mellitus and/or PTSD, is denied. Service connection for hypertension, and to include as due to in-service exposure to herbicides and/or secondary to service-connected diabetes mellitus and/or PTSD, is denied. ____________________________________________ MICHAEL D. LYON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs