Citation Nr: 1324933 Decision Date: 08/06/13 Archive Date: 08/13/13 DOCKET NO. 06-23 142 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for a low back disorder. 2. Entitlement to service connection for hypertension. 3. Entitlement to service connection for an inguinal hernia. 4. Entitlement to service connection for respiratory disability, to include as claimed as pulmonary tuberculosis (PTB) or positive Mantoux /purified protein derivative (PPD) test. REPRESENTATION Veteran represented by: Texas Veterans Commission WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD Helena M. Walker, Counsel INTRODUCTION The Veteran served in the U.S. Army Reserves (USAR) from January 1983 to January 2004. During his USAR service, he served on active duty from January 18 to June 21, 1991; from January 3 to August 14, 1993; from February 1, 1994 to September 30, 1995; and from January 27 to July 15, 2003. He also had a period of active duty for training (ACDUTRA) from September 9 to September 20, 1997. He also had many periods of inactive duty for training (INACDUTRA) This matter comes before the Board of Veterans' Appeals (BVA or Board) on appeal from February and May 2005 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas, which denied the benefits sought on appeal. In January 2009, April 2011, and December 2011, the Board remanded the claims for additional development. The Veteran testified at a Travel Board hearing before the undersigned Acting Veterans Law Judge (AVLJ) in July 2008. A transcript of the hearing is associated with the claims file. Review of the claims file shows that there is now substantial compliance with the directives of the Board's prior remands. In this regard, the Appeals Management Center (AMC) made multiple attempts to retrieve the Veteran's outstanding records related to his reserve duty and potential periods of ACDUTRA/INADCUTRA. Requests were made to the National Personnel Records Center (NPRC), the Defense Personnel Records Information Retrieval System (DPRIS), Defense Finance and Accounting Service (DFAS). All available DPRIS records, including Leave and Earning (LES) statements, are associated with the claims file. In a June 2012 memorandum, the AMC presented a Memorandum of Unavailability with respect to the records that could verify each specific period of ACDUTRA and INACDUTRA between January 1983 and January 2004. However, as discussed below (in the section addressing VCAA duty to assist compliance), the Board finds that the AMC's attempts to retrieve these records was adequate in this matter and in substantial compliance with the Board's remand directives. The Board is therefore satisfied there was compliance with the remand directives. See Stegall v. West, 11 Vet. App. 268 (1998) and Dyment v. West, 13 Vet. App. 141, 146- 47 (1999). A Court or Board remand confers upon the Veteran the right to substantial, but not strict, compliance with that order. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). In addition to the paper claims files, the Veteran also has an electronic claims file in Virtual VA. The Board has reviewed both the paper and electronic claims files in rendering this decision. The issues of entitlement to service connection for a low back disability and hypertension are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the AMC, in Washington, DC. FINDINGS OF FACT 1. The Veteran's right inguinal hernia was not caused or aggravated by an event, injury, or disease incurred in active duty, ACDUTRA, or INACDUTRA. 2. A positive PPD testing was noted in service, but the evidence does not show an active tuberculosis disease process. CONCLUSIONS OF LAW 1. The criteria for service connection for right inguinal hernia residuals have not been met. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2012). 2. A positive PPD test is a laboratory finding but no underlying disability has been shown. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all the evidence submitted by or on behalf of the Veteran. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). Veterans Claims Assistance Act of 2000 (VCAA) With respect to the Veteran's claims, the VA has met all statutory and regulatory notice and duty to assist provisions. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the Veteran and his or her representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II), the United States Court of Appeals for Veterans Claims (Court) held that VA must inform the Veteran of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) that the Veteran is expected to provide; and (4) request that the Veteran provide any evidence in his or her possession that pertains to the claim. The requirement of requesting that the Veteran provide any evidence in his possession that pertains to the claim was eliminated by the Secretary during the course of this appeal. See 73 Fed. Reg. 23353 (final rule eliminating fourth element notice as required under Pelegrini II, effective May 30, 2008). Thus, any error related to this element is harmless. VCAA letters dated in March 2005, April 2005, March 2006, and February 2009 fully satisfied the duty to notify provisions. See 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b)(1) (2012); Quartuccio, at 187. The Veteran was advised that it was ultimately his responsibility to give VA any evidence pertaining to the claims. The letters informed him that additional information or evidence was needed to support his claims, and asked him to send the information or evidence to VA. See Pelegrini II, at 120-121. The March 2006 letter also explained to the Veteran how disability ratings and effective dates are determined. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Board is aware that the March 2005 and April 2005 letters pre-dated the Dingess decision. As noted above, VA provided the Veteran with corrective notice that is compliant with Dingess following additional notice in February 2009. The most recent readjudication of the claims was in a September 2012 Supplemental Statement of the Case. Accordingly, there are no notice deficiencies requiring corrective action in this case. See Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007). As noted above, the Veteran also was afforded a hearing before the undersigned AVLJ during which he presented oral argument in support of his service connection claims. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 3.103(c)(2) (2012) requires that the VLJ/DRO who chairs a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, the VLJ generally explained the issues on appeal during the hearing and specifically inquired as to facts that would tend to support his claims, she also suggested the submission of evidence that would be beneficial to the Veteran's claim. Significantly, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor has he identified any prejudice in the conduct of the Board hearing. By contrast, the hearing focused on the elements necessary to substantiate the claim, and the Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claim. As such, the Board finds that, consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). Furthermore, even if any notice deficiency is present in this case, the Board finds that any prejudice due to such error has been overcome in this case by the following: (1) based on the communications sent to the Veteran over the course of this appeal, the Veteran clearly has actual knowledge of the evidence the Veteran is required to submit in this case; and (2) based on the Veteran's contentions as well as the communications provided to the Veteran by VA, it is reasonable to expect that the Veteran understands what was needed to prevail. See Shinseki v. Sanders/Simmons, 129 S. Ct. 1696 (2009); Fenstermacher v. Phila. Nat'l Bank, 493 F.2d 333, 337 (3d Cir. 1974) ("[N]o error can be predicated on insufficiency of notice since its purpose had been served."). In order for the Court to be persuaded that no prejudice resulted from a notice error, "the record must demonstrate that, despite the error, the adjudication was nevertheless essentially fair." Dunlap v. Nicholson, 21 Vet. App. 112, 118 (2007). In this case, the Veteran has been continuously represented by an experienced state service organization and has submitted argument in support of his claims. These arguments have referenced the applicable law and regulations necessary for a grant of service connection. Thus, the Board finds that the Veteran has actual knowledge as to the information and evidence necessary for him to prevail on his claims and is not prejudiced by a decision in this case. As such, a remand for additional notice would serve no useful purpose and would in no way benefit the Veteran. Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on the VA with no benefit flowing to the Veteran are to be avoided). The Board also concludes VA's duty to assist has been satisfied. The Veteran's service treatment records (STRs) and VA medical records are in the file. Private medical records identified by the Veteran have been obtained, to the extent possible. The Veteran has at no time otherwise referenced outstanding records that he wanted VA to obtain or that he felt was relevant to the claims. The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4)(i) (2012). In this case, the Veteran was provided VA examinations in March 2009. The examiner considered the Veteran's complaints, as well as the service treatment records, post-service treatment records, and conducting a physical examination. Based on the foregoing, the examiner concluded that the Veteran's right inguinal hernia was not caused or aggravated by an event, disease, or injury incurred during active service or ACDUTRA/INACDUTRA. Additionally, the Veteran was not found to have a disability for VA compensation purposes with respect to his positive PPD test. Therefore, as the opinions were based on review of the claims file, including the Veteran's statements, and provided an extensive rationale for the opinions provided, the Board concludes that the opinions provided are adequate. Given the foregoing, the Board finds the evidence of record to be thorough, complete, and sufficient upon which to base a decision with respect to the Veteran's claim for service connection. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). As such, the Board finds that the medical evidence of record is sufficient to adjudicate the Veteran's claims. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Legal Criteria Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection 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); see also Caluza v. Brown, 7 Vet. App. 498 (1995). The Veteran contends that he incurred the disabilities on appeal as a result of in-service incidents or exposures during his ACDUTRA, his active duty service, or his INACDUTRA. Service connection may be granted for disability resulting from disease or injury incurred during ACDUTRA or injuries incurred during INACDUTRA. See 38 U.S.C.A. §§ 101(24), 106 (West 2002); 38 C.F.R. § 3.6 (2012). Service connection is not legally merited when the disability results from a disease process during INACDUTRA. See, e.g., Brooks v. Brown, 5 Vet. App. 484, 487 (1993). Reserve and National Guard service generally means ACDUTRA and INACDUTRA. ACDUTRA is full time duty for training purposes performed by Reservists and National Guardsmen pursuant to 32 U.S.C.A. §§ 316, 502, 503, 504, or 505; 38 U.S.C.A. § 101(22) (West 2002); 38 C.F.R. § 3.6(c) (2012). Basically, this refers to the two weeks of annual training, sometimes referred to as "summer camp," that each Reservist or National Guardsman must perform each year. It can also refer to the Reservist's or Guardsman's initial period of training. INACDUTRA includes duty, other than full-time duty, performed for training purposes by Reservists and National Guardsmen pursuant to 32 U.S.C.A. §§ 316, 502, 503, 504, or 505; 38 U.S.C.A. § 101(23) (West 2002); 38 C.F.R. § 3.6(d) (2012). Basically, this refers to the twelve four-hour weekend drills that each Reservist or National Guardsman must perform each year. These drills are deemed to be part-time training. When a claim for service connection is based only on a period of ACDUTRA, there must be evidence that the Veteran became disabled as a result of a disease or injury incurred or aggravated in the line of duty during the period of ACDUTRA. Smith v. Shinseki, 24 Vet. App. 40 (2010). In the absence of such evidence, the period of ACDUTRA would not qualify as "active military, naval, or air service," and the Veteran would not qualify as a "veteran" by virtue of the ACDUTRA alone. Id. In the service connection context, for example, this means that the presumption of soundness upon entry into service and the presumptive service connection provisions of 38 C.F.R. § 3.307, applicable to active duty, would not apply to ACDUTRA or INACDUTRA. 38 U.S.C.A. §§ 1111, 1112, 1137; 38 C.F.R. § 3.307. Thus, service connection on a presumptive basis is not available where the only service performed is ACDUTRA or INACDUTRA. See Biggins v. Derwinski, 1 Vet. App. 474, 476-78 (1991). By statute, a Veteran will be considered to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service, or where clear and unmistakable evidence demonstrates that an injury or disease existed prior thereto and was not aggravated by service. 38 U.S.C.A. § 1111 (West 2002). Only such conditions as are recorded in examination reports are to be considered as noted. 38 C.F.R. § 3.304(b) (2012). This presumption also does not apply to ACDUTRA and INACDUTRA service, only active duty. The same is true of the presumptions of soundness and aggravation. See Smith v. Shinseki, 24 Vet. App. 40 (2010); Biggins v. Derwinski, 1 Vet. App. 474, 478 (1991). With disability compensation claims, VA adjudicators are directed to assess both medical and lay evidence. In certain circumstances lay evidence may be sufficient to establish a medical diagnosis or nexus. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). In addressing lay evidence and determining its probative value, if any, attention is directed to both competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). See Layno v. Brown, 6 Vet. App. 465, 469 (1994). In terms of competency, lay evidence has been found to be competent with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See Barr v. Nicholson, 21 Vet. App. 303, 308-09 (2007) (concerning varicose veins); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (a dislocated shoulder); Charles v. Principi, 16 Vet. App. 370, 374 (2002) (tinnitus); Falzone v. Brown, 8 Vet. App. 398, 405 (1995) (flatfoot). That notwithstanding, a Veteran is not competent to provide evidence as to more complex medical questions and, specifically, is not competent to provide an opinion as to etiology in such cases. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (concerning rheumatic fever); see also Routen v. Brown, supra. The Board may weigh the absence of contemporaneous medical evidence against the lay evidence in determining credibility, but the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006); but see Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000) (evidence of a prolonged period without medical complaint after service can be considered along with other factors in the analysis of a service connection claim). Factual Background and Analysis Hernia The Veteran maintains that he had an inguinal hernia related to his active duty. He indicated that during his April 1989 weekend training, he recalled feeling a pull in his groin area while lifting heavy parts. He stated that it continued to bother him and he sought treatment in May 1989 and was told he had a right inguinal hernia. He contends that his inguinal hernia residuals are related to his ACDUTRA or INACDUTRA. In a July 1988 STR, the Veteran sought treatment for abdominal pain in the right lower quadrant. The treating professional detected no evidence of abdominal or inguinal hernia. The diagnosis was muscle strain. In May 1989, the Veteran underwent a right inguinal hernia repair. He again complained of having pain in the right groin area in January 1991. In a June 1991 report of medical history, the Veteran indicated that he had a history of a rupture/hernia. The examining personnel indicated that the Veteran had a hernia repair performed when he was 25 years old. In a September 1995 report of medical history, the Veteran indicated that he had a hernia repair in 1989. Physical examination at that time revealed no current palpable hernia found, but he did have scarring from the herniorrhaphy. In a February 2001 treatment record, the Veteran complained of pain in the lower quadrant. He indicated that he had a history of hernia surgery in the same area. The Veteran described feeling a pop of pain while reaching across the desk that day, and the pain had increased since. In 2001 to 2002, the Veteran was treated for nerve entrapment of the genitofemoral and ilioinguinal nerves on the right side. He underwent surgery to implant a post-peripheral nerve stimulator in August 2001. In a July 2003 report of medical history, the Veteran indicated that he had a hernia in the past. The examiner noted that he had hernia surgery in 1988 Private treatment records show complaints of orchialgia after being treated for epididymitis. X-ray and ultrasound of the testes were within normal limits. During his July 2008 hearing, the Veteran reported that he first felt a pull in his groin area during his May 1989 drill weekend (May 2 to May 3, 1989). He advised that on Monday, he could not stand the pain anymore and sought treatment for it. He indicated that the surgery was on Monday, May 4, 1989. The Board notes that May 4, 1989, the date on which the Veteran underwent right inguinal hernia repair was a Thursday, not a Monday as the Veteran contends. Further, he described his "drill weekend" as being from May 2 to May 3, 1989, when in reality those dates were a Tuesday and Wednesday, respectively. The Veteran underwent a VA hernia examination in March 2009, during which he reported undergoing a right inguinal herniorrhaphy in 1989 (prior to active duty). There were resultant complications associated with the ilioinguinal and femoralgenital nerves. The examiner indicated that there was no treatment for herniorrhaphy complications noted in his STRs. The examiner diagnosed the Veteran as having status-post right inguinal hernia. The examiner opined that the Veteran's inguinal hernia residuals are less likely than not caused or aggravated by his military service. In reaching this conclusion, the examiner indicated that the Veteran's symptoms preexisted his service, and he was not treated for any residuals during service. There is no clinical opinion to the contrary. Upon careful review of the evidence of record, the Board finds that the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for residuals of a right inguinal hernia. It is clear from the record that the Veteran has a history of right inguinal hernia, status-post herniorrhaphy. As noted above, the Veteran contends that this disability was either proximately caused or aggravated by his active duty military service or ACDUTRA/INACDUTRA. Based on the evidence of record, the Board concludes it was not. The Board finds that the opinion expressed in the March 2009 VA examination report to be credible and probative. The report was based on interview with the Veteran, his reported medical history, appropriate diagnostic testing, and physical examination. Further, a complete and thorough rationale is provided for the March 2009 opinion from the VA examiner. Although the Veteran was shown to have a history of right inguinal hernia in 1989, the evidence of record shows that this was not caused or aggravated by his active duty or ACDUTRA/INACDUTRA. The March 2009 VA examiner indicated that the Veteran's inguinal hernia preexisted service and was not aggravated thereby as he was not treated for complaints related to his right inguinal area during service (or during a period of ACDUTRA or INACDUTRA). This opinion is fully explained and consistent with the evidence of record. In that regard, the Board observes that no medical professional has opined as to a relationship between the Veteran's current right inguinal hernia residuals and his active duty or ACDUTRA/INACDUTRA. The medical professional's opinion clearly contemplated both causation and aggravation. Furthermore, the Board has considered the Veteran's contentions that his current right inguinal hernia had its onset during his weekend drill in May 1989. In this regard, the Board acknowledges that the Veteran is competent to give evidence about what he experienced; for example, he is competent to discuss the existence of right groin pain and a pulling sensation. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). However, in most cases, the Veteran is not competent to render an opinion as to the cause or etiology of any current disorder because he does not have the requisite medical knowledge or training. See Rucker v. Brown, 10 Vet. App. 67, 74 (1997) (stating that competency must be distinguished from weight and credibility, which are factual determinations going to the probative value of the evidence). In this instance, therefore, the Veteran as a lay person has not been shown to be capable of making medical conclusions, especially as to complex medical diagnoses such as a link between his current right inguinal hernia residuals and his May 1989 weekend drill. As such, the Board ascribes far more weight to the conclusions of the medical professional who concluded that the Veteran's current right inguinal hernia residuals are less likely than not caused or aggravated by active duty or ACDUTRA/INACDUTRA. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (explaining in footnote 4 that a veteran is competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions). In short, the most probative medical evidence specifically rules out a relationship between the Veteran's current right inguinal hernia residuals and his active duty or ACDUTRA/INACDUTRA. The Board places more weight on the opinion of the competent VA medical professional who provided the March 2009 opinion, based on review of the medical records and claims file and/or interview of the Veteran and/or physical examination, than on the Veteran's lay assertions that his right inguinal hernia occurred during his May 2 to May 3, 1989, weekend drill. The Board has considered the Veteran's contentions that he first had an inguinal hernia during his May 1989 weekend drill. The Board, however, has "the authority to discount the weight and probity of evidence in the light of its own inherent characteristics and its relationship to other items of evidence." Madden v. Brown, 125 F.3d 1477, 1481 (Fed. Cir. 1997). In this case, the "inherent characteristics" of the Veteran's current statements as to the onset of his right inguinal hernia is inconsistent with the objective evidence of record. In that regard, the Veteran was not shown to have any aggravation of his right inguinal hernia during active duty or ACDUTRA/INACDUTRA. Additionally, his testimony presented during his July 2008 hearing stating that his inguinal hernia had its onset during a May 2 to May 3, 1989 weekend drill completely lacks credibility. The Veteran contends that he experienced such pain during his May 1989 weekend drill that he had to go on Monday, May 4, 1989, for treatment and underwent a repair that same day. The Board finds that the evidence of record indeed shows that the Veteran underwent this repair on May 4, 1989. The Board notes, however, that May 4, 1989, was not a Monday, it was a Thursday. Likewise, May 2 to May 3, 1989, was not a weekend during which he would have had INACDUTRA. It was a Tuesday and Wednesday. Moreover, the available records related to the Veteran's USAR do not show that he was on ACDUTRA or INACDUTRA during that timeframe. In short, the Board gives greater credence and weight to the contemporaneous and near contemporaneous medical records showing no in-service right inguinal hernia or repair, nor was any aggravation of the right inguinal hernia shown during service or a period of ACDUTRA/INACDUTRA. Therefore, the Board finds that the Veteran's allegations that he first experienced a pain in his groin during a weekend drill and had surgery that Monday not credible. In summary, the preponderance of the evidence demonstrates that the Veteran's right inguinal hernia and its residuals were not caused or aggravated by his military service or ACDUTRA. In that regard, the Board finds the conclusions of the March 2009 VA opinion provider of significantly more probative value than those of the Veteran based on his non-credible claim that the injury to his right inguinal area occurred during a period of ACDUTRA or INACDUTRA. Finally, the Veteran has not met his burden of showing that a preexisting injury to the right inguinal area increased during a period of service and that it was beyond the natural progress of the disorder. As such, the Board finds that the benefit of the doubt doctrine is not for application, and that the claim must be denied. See generally Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F.3d 1361 (Fed Cir. 2001). Tuberculosis and a Positive PPD Test The Veteran seeks service connection for a positive PPD test and/or pulmonary tuberculosis. He maintains that he first had a positive PPD test during active duty. He seeks payment for the 9 months of medication and lifetime of x-rays as a result of the positive PPD test. In service, he denied known exposure to pulmonary tuberculosis (PTB) [except for one examination in January 1983 when he checked that he had lived with someone who had PTB and then scratched that entry out]; and was apparently never diagnosed therewith, although he had periodic respiratory problems to include shortness of breath, asthma for which he used an inhaler, sinusitis and hay fever and chest pain. The Veteran was given a PPD testing in February 2003, which was negative. PPD testing performed again in July 2003 was positive. Following the Veteran's positive PPD test, he was given a chest x-ray in July 2003. The x-ray showed no pulmonary disease, and he was assessed as having a normal chest x-ray. VA treatment records show that the Veteran was given izoniazid (INH) for 9 months for treatment. He indicated that he will continue to receive yearly chest x-rays. In March 2009, the Veteran was afforded a VA examination to determine whether he had a lung disability related to his military service. The examiner indicated that the Veteran had a negative PPD test in January 2003, but in July 2003, it was reactive. Chest x-ray performed in 2003 was negative, as was a chest x-ray performed in 2004. The examiner diagnosed the Veteran as having reactive TB skin test, but no tuberculosis disease. Upon careful review of the evidence of record, the Board finds that the Veteran is not entitled to service connection for a disability manifested by a positive PPD test. As has been discussed with the Veteran during the course of the appeal, including at the hearing, the Board observes that a positive PPD test is not the same thing as a medical diagnosis of active tuberculosis; nor is it by itself considered a disability that can be service-connected. Rather, a PPD test result is considered to be a laboratory finding used in exploring a possible diagnosis of tuberculosis; purified protein derivative examination is used to test for exposure to Mycobacterium tuberculosis. See DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 1498, 1962 (30th ed. 2003). The Board notes that under 38 C.F.R. § 4.1, the term "disability" means impairment in earning capacity resulting from diseases and injuries and their residual conditions. See also Hunt v. Derwinski, 1 Vet. App. 292, 296 (1991); Allen v. Brown, 7 Vet. App. 439 (1995). The Board notes that a symptom, without a diagnosed or identifiable underlying malady or condition, does not in and of itself constitute a "disability" for which service connection may be granted. See Sanchez-Benitez v. West, 13 Vet. App. 282 (1999). A laboratory finding does not ultimately constitute a disability in and of itself, absent a separate diagnosis. See 61 Fed. Reg. 20440, 20445 (May 7, 1996) (regarding cholesterol testing). Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The Board appreciates the Veteran's passionate arguments with respect to his positive PPD testing. And acknowledges his contentions that he was required to pay out of pocket for his INH treatment. Unfortunately, a positive PPD test alone is not a "disability" for VA compensation benefits purposes. Without evidence of an underlying disability, the preponderance of the evidence is against the claim and the appeal is denied. ORDER Service connection for residuals of an inguinal hernia is denied. Service connection for a positive PPD test is denied. REMAND Upon preliminary review of the evidence of record, the Board finds that further development is necessary with respect to the Veteran's claims of entitlement to service connection for a low back disability and hypertension. Some factual background related to these two disabilities is noted in the sections below. The Veteran was provided VA examination for both of these disabilities in 2009, during which the examiner provided negative nexus opinions with respect to whether either of these disabilities was caused or aggravated by active duty. Since the 2009 VA examinations, the Veteran has alternatively contended that his low back disability and hypertension are secondary to his service-connected disabilities. In other words, he contends that a service-connected disability has caused or chronically worsened/aggravated his low back disability and hypertension. Although the VA examination reports address whether the Veteran's hypertension and back disability are directly related to service or were aggravated during a period of active duty, the 2009 reports do not present (or even reasonably suggest) any answer to the question of whether the hypertension or low back disability may have been caused or aggravated (permanently worsened beyond natural progression) by the Veteran's service-connected disabilities. Neither the scope of the rationale nor the language of the opinions provides a basis for the Board to make an informed determination as to whether the hypertension and low back disability have been aggravated by a service-connected disability. As such, the Board finds the 2009 VA medical opinions to be inadequate in that it only addresses direct service connection and not secondary service connection. 38 C.F.R. § 3.310. The Board observes that the United States Court of Appeals for Veterans Claims (Court) held that the phrases "caused by" and "related to" do not address the aggravation aspect of secondary service connection. Allen v. Brown, 7 Vet. App. 439, 449 (1995). Because the required opinions have still not been adequately provided, a remand is necessary so that the Veteran may be afforded new VA examinations to determine the etiology of his low back disability and hypertension. To ensure completeness of the record, ongoing medical records should be obtained. 38 U.S.C.A. § 5103A(c) (West 2002); see also Bell v. Derwinski, 2 Vet. App. 611 (1992) (VA medical records are in constructive possession of the agency, and must be obtained if the material could be determinative of the claim). Low Back The Veteran contends that at the time of a 1993 in-service injury to his right shoulder he also injured his low back. He contends that treating personnel were more focused on his shoulder than his back. He stated that his low back problems were further aggravated when a 5 ton door hit him in October 1997. In July 1993, the Veteran sought treatment for complaints of pain to the lower left side of his back. He reported that he was working inside a crate and when he tried to get out, the crate tipped and he fell over, hitting his left flank. X-ray of the spine revealed slight misalignment of the spinous processes, but no fractures. He was given pain medications and muscle relaxers. The assessment was musculoskeletal low back pain. In what appears to be September 1997, the Veteran was placed on a profile with respect to his low back complaints. He was prohibited from performing pushups or lifting greater than 10 pounds for one week. In an October 1997 STR, the Veteran was treated for a right shoulder injury following being hit by a 5 ton truck door. When he was hit, he fell to the floor. At that time, he did not report any back pain or back-related complaints, nor did he so report in subsequent treatments related to the shoulder injury. In a November 1997 examination and line of duty determination with respect to the October 1997 injury, there was no notation of any back disability. Although the shoulder injury was incurred in the line of duty, there was no finding of any related back disability. Private treatment records dated in 1998 show that the Veteran was rear-ended by a truck in August 1998. X-rays of the cervical and lumbar spines were normal, but he was diagnosed as having a cervical-lumbar strain. At that time, he did not report that this occurred during a period of ACDUTRA/INACDUTRA. In an October 1998 treatment record, the doctor opined that he did not think the strain would result in a permanent impairment. In September 2000, the Veteran was treated for a lumbar strain. There was a palpable mild spasm in the right low back. There was no mention of any relationship to active duty or ACDUTRA/INACDUTRA. In a November 2000 medical assessment, the examining professional indicated that the Veteran's had complaints of recurrent low back pain. X-rays were within normal limits, but he was diagnosed as having a lumbar strain and is taking pain medications for treatment. In a July 2003 report of medical history, the Veteran indicated that he did not have any recurrent back pain or any back problem. During the Veteran's July 2008 hearing, he again testified that his documented in-service injuries from falling in a crate and being hit by a 5 ton door caused his current low back disability. He also indicated that he was unable to get treatment for his back disability soon after active duty or ACDUTRA/INACDUTRA because he was uninsured. The Veteran was afforded a VA examination of the spine in March 2009 during which he reported the onset of his low back pain in 1987. He advised that it is located in the middle to left low back with numbness and tingling in the left lower extremity. The Veteran described the documented 1993 injury to his back in Panama, and asserted that he also hurt his back in 1997 when he was hit with the truck door. He stated that all the attention was on his right shoulder. The Veteran was diagnosed as having lumbosacral strain. Following review of the claims file and interview and examination of the Veteran, the examiner opined that the Veteran's current low back strain is less likely than not caused or aggravated by his military service. In reaching this conclusion, the examiner indicated that the Veteran had a pre-service motorcycle accident and a motor vehicle accident following which he was diagnosed as having a lumbar strain. He indicated that although the Veteran had a 1993 fall in service, there was no more documented back problems in service, and the fall is less severe than a car or motorcycle accident. In a May 2011 statement, the Veteran indicated that his back disability was aggravated by his ACDUTRA and weekend training. He also contends that he gained weight as a result of his right shoulder disability and this likely aggravated his back problems. Hypertension Following being hit by a 5 ton truck door in October 1997, the Veteran was noted to have elevated blood pressure. He was advised to check his blood pressure for the previous 5 days, but he did not show up. The treating professional indicated that the blood pressure readings taken that day were normal. A March 2000 private treatment record indicates the Veteran's report of at least a 10 year history of high blood pressure readings. He and his wife expressed their belief that he may need to be placed on hypertension medication. In a September 2000 treatment record, the physician indicated that the Veteran was being treated for hypertension. In a November 2000 medical examination, the treating professional indicated that the Veteran had been on hypertension medications since March 2000. In a July 2003 STR, the Veteran indicated that he was hypertensive and was on medications. In a July 2003 report of medical history, the Veteran was noted to have a history of high blood pressure since 1997. The Veteran sought VA treatment for his high blood pressure in 2003, after discharge from a period of active duty. The Veteran was afforded a VA hypertension examination in March 2009, during which he was diagnosed as having hypertension. The Veteran reported the onset of his hypertension was in 1997 in the course of treatment for his right shoulder injury. Following review of the claims file and after interview and examination of the Veteran, the examiner opined that the Veteran's hypertension was not caused or aggravated by his military service. In reaching this conclusion, the examiner indicated that the Veteran was not diagnosed as having or treated for hypertension or high blood pressure during service. In addition, he has a family history of hypertension, and the Veteran's father had a stroke while in his 40s. In a May 2011 statement, the Veteran indicated that his hypertension may be secondary to his service-connected right shoulder disability or PTSD. Accordingly, the case is REMANDED for the following action: 1. Obtain any outstanding treatment records related to the Veteran's low back disability and hypertension. 2. Schedule a VA examination by a physician with the requisite expertise to determine the etiology of the Veteran's hypertension. The claims folders, including any pertinent evidence in Virtual VA, should be forwarded to the examiner for review. The examiner should be directed to elicit a complete history from the Veteran. Following review of the claims file and examination of the Veteran, the examiner should provide an opinion regarding whether it is at least as likely as not (i.e., probability of 50 percent) that hypertension is related to any disease or injury in service. The examiner should also provide an opinion regarding whether it is at least as likely as not (i.e., probability of 50 percent) that hypertension was caused or aggravated by the Veteran's service-connected disabilities-including his service-connected posttraumatic stress disorder and right shoulder disabilities. The examiner is advised that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. A discussion of the underlying reasons for all opinions expressed must be included in the examination report, to include reference to pertinent evidence where appropriate. If the examiner is unable to offer any of the requested opinions, it is essential that the examiner offer a rationale for the conclusion that an opinion cannot be provided without resort to speculation, together with a statement as to whether there is additional evidence that might enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. See Jones v. Shinseki, 23 Vet. App. 382 (2010). 3. Schedule a VA examination by a physician with the requisite expertise to determine the etiology of the Veteran's low back disability. The claims folders, including any pertinent evidence in Virtual VA, should be forwarded to the examiner for review. The examiner should be directed to elicit a complete history from the Veteran. Following review of the claims file and examination of the Veteran, the examiner should provide an opinion regarding whether it is at least as likely as not (i.e., probability of 50 percent) that low back disability is related to any disease or injury in service. The examiner should also provide an opinion regarding whether it is at least as likely as not (i.e., probability of 50 percent) that low back disability was caused or aggravated by the Veteran's service-connected disabilities-including his service-connected posttraumatic stress disorder and right shoulder disability. The examiner is asked to specifically address the Veteran's contention that he gained weight as a result of his right shoulder disability and this aggravated his back disability. The examiner is advised that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. A discussion of the underlying reasons for all opinions expressed must be included in the examination report, to include reference to pertinent evidence where appropriate. If the examiner is unable to offer any of the requested opinions, it is essential that the examiner offer a rationale for the conclusion that an opinion cannot be provided without resort to speculation, together with a statement as to whether there is additional evidence that might enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. See Jones v. Shinseki, 23 Vet. App. 382 (2010). 4. After completion of the above and any further development deemed necessary by the AMC/RO, the issues on appeal should be readjudicated. If any benefit sought is not granted, the Veteran and his representative should be furnished an appropriate supplemental statement of the case and be afforded an opportunity to respond. Thereafter, the case should be returned to the Board for further appellate review. By this remand, the Board intimates no opinion as to any final outcome warranted. No action is required of the Veteran until he is otherwise notified but he has the right to submit additional evidence and argument on the 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). ______________________________________________ J. K. BARONE Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs