Citation Nr: 1327608 Decision Date: 08/28/13 Archive Date: 09/05/13 DOCKET NO. 08-11 833 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to service connection for a digestive disorder, diagnosed as gastroesophageal reflux disease (GERD), previously claimed as stomach ulcers and esophagitis. 2. Entitlement to service connection for chronic fatigue syndrome (CFS), including as a qualifying chronic disability under 38 C.F.R. § 3.317 and encompassing complaints of achy joints, sore/weak muscles, recurrent rash of groin and neck, chronic bronchitis with coughing and shortness of breath, and low-grade fever, chills at sunset, tender glands, and a general feeling of not being well. ATTORNEY FOR THE BOARD C. Kedem, Counsel INTRODUCTION The Veteran served on active duty in the military from September 1990 to June 1991 and from January 2003 to July 2004, including a tour in Southwest Asia. He also had additional service in the Tennessee Army National Guard. This appeal to the Board of Veterans' Appeals (Board/BVA) is from January 2006 and February 2009 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). In October 2010, the Board declined to reopen a claim of entitlement to service connection for headaches, but reopened a claim for service connection for stomach ulcers and esophagitis on the basis of new and material evidence. The Board also granted a claim of entitlement to service connection for posttraumatic stress disorder (PTSD). The Board remanded for additional development claims of entitlement to service connection for bilateral hearing loss, tinnitus, a digestive disorder diagnosed as GERD and previously claimed as stomach ulcers and esophagitis, as well as a claim of service connection for CFS, including as a qualifying chronic disability under 38 C.F.R. § 3.317 and encompassing complaints of achy joints, sore/weak muscles, recurrent rash of groin and neck, chronic bronchitis with coughing and shortness of breath, and low-grade fever, chills at sunset, tender glands, and a general feeling of not being well, and a claim for a total disability rating based on individual unemployability (TDIU). In a November 2011 decision since issued, the Appeals Management Center (AMC) granted the claims of entitlement to service connection for bilateral hearing loss and tinnitus. And in an even more recent May 2012 decision, the AMC also granted the claim for a TDIU, also increased the rating for the PTSD from 50 to 70 percent, and as well determined the Veteran had established his eligibility for Dependents' Educational Assistance (DEA). Since he did not, in response, appeal the ratings or effective date assigned for his bilateral hearing loss and tinnitus, or the effective date for his TDIU, these claims are no longer at issue. See Grantham v. Brown, 114 F.3d 1156, 1158-59 (Fed. Cir. 1997) (indicating he had to separately appeal these "downstream" issues). With respect to the claims remaining on appeal, the Board remanded them to the RO via the AMC for still further development in September 2012. Specifically, the Board requested supplemental medical comment, as the evidence then of record still was insufficient to decide these remaining claims. The required additional development since has been completed, however, at least as concerning the claim for CFS, etc., so now allowing the Board to proceed with its adjudication of this claim. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (another remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (Fed. Cir. 2002). But the issue of entitlement to service connection for a digestive disorder, diagnosed as GERD and previously claimed as stomach ulcers and esophagitis, requires more development before being decided on appeal. So the Board is again remanding this claim to the RO via the AMC. FINDINGS OF FACT 1. The Veteran does not suffer from CFS, and he does not suffer from sore/weak muscles, low grade fever, chills at sunset, tender glands, or a general feeling of not being well as a result of an undiagnosed illness. 2. Achy joints have been attributed to degenerative joint disease of multiple joints; this disability is not causally related to his service and did not manifest until years after his separation from service. 3. A skin rash disability has been attributed to a known diagnosis, and it is not causally related to his service or to any incident of his service. 4. A respiratory disorder has been attributed to a known diagnosis, and it is from the chronic use of tobacco (smoking) in a claim received after June 9, 1998. CONCLUSION OF LAW The criteria are not met for service connection for CFS, including as a qualifying chronic disability under 38 C.F.R. § 3.317 and encompassing complaints of achy joints, sore/weak muscles, recurrent rash of groin and neck, chronic bronchitis with coughing and shortness of breath, and low-grade fever, chills at sunset, tender glands, and a general feeling of not being well. 38 U.S.C.A. §§ 1103, 1110, 1117, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.300, 3.303, 3.307, 3.309, 3.317 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA and implementing regulations imposes obligations on VA to provide claimants with notice and assistance upon receipt of a complete or substantially complete application. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.326(a) (2012). The notice requirements of VCAA require VA to (1) notify the claimant of the information or evidence necessary to substantiate the claim, including (2) apprising them of what subset of the necessary information or evidence, if any, the claimant is to provide and (3) what subset of the necessary information or evidence, if any, VA will attempt to obtain on the claimant's behalf. The so-called "fourth element" of the notice requirement requesting the claimant to provide any evidence in his personal possession pertaining to the claim was removed from the language of 38 C.F.R. § 3.159(b)(1). See 73 Fed. Reg. 23,353-356 (April 30, 2008). The United States Court of Appeals for Veterans Claims (Court/CAVC) issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which held that these notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service-connection claim. Those five elements are: (1) Veteran status; (2) existence of a disability; (3) a connection between the Veteran's military service and the disability; but also the "downstream" (4) degree of disability, i.e., disability rating; and (5) effective date. The Court (CAVC) held in Pelegrini v. Principi, 18 Vet. App. 112 (2004), that to the extent possible the VCAA notice should be provided to the claimant before an initial unfavorable decision on the claim. Pelegrini at 119-20. If, however, for whatever reason it was not, or the notice provided was inadequate or incomplete, this timing error can be effectively "cured" by providing any necessary VCAA notice and then readjudicating the claim - including in a statement of the case (SOC) or supplemental SOC (SSOC), such that the intended purpose of the notice is not frustrated and the Veteran is given an opportunity to participate effectively in the adjudication of the claim. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007). VCAA notices errors, even when shown to have occurred, are not presumptively prejudicial, rather, must be judged on a case-by-case basis. And as the pleading party attacking the agency's decision, the Veteran, not VA, has this burden of proof of not only establishing error, but, above and beyond that, showing how it is unduly prejudicial, meaning outcome determinative of the claim. Shinseki v. Sanders, 129 S. Ct. 1696 (2009). Here, in July 2005 and May 2008 letters, the RO provided notice to the Veteran regarding what information and evidence was needed to substantiate his claim of entitlement to service connection, including as due to undiagnosed illness, as well as what information and evidence he needed to submit versus the information and evidence VA would obtain for him. The notice also included information concerning the "downstream" disability rating and effective date elements of his claim. Moreover, although some of that notice, but not all, preceded the initial adjudication of his claim, any defect in the timing of the notice that did not precede the initial adjudication of the claim since has been rectified with the readjudication of the claim in February 2009 and even more recently on multiple additional occasions, including in the May 2013 SSOC. See Prickett v. Nicholson, 20 Vet. App. 370, 376-78 (2006) (validating the remedial measures of issuing fully compliant VCAA notification and re-adjudicating the claim in the form of an SOC to cure timing of notification defect). The Board also is satisfied VA has made reasonable efforts to obtain relevant records and evidence, including affording a VA medical examination. To that end, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure the examination or opinion is adequate. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the VA opinions and findings obtained in this case are adequate because, in the aggregate, they are predicated on a full reading of the service treatment records (STRs), VA clinical records, private medical records, and the Veteran's statements. Moreover, the rationales provided, in toto, have been fully substantiated. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion regarding this claim has been met. 38 U.S.C.A. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4). The information and evidence that has been associated with the claims file for consideration includes, as mentioned, the Veteran's STRs, VA examination reports, private medical records, VA clinical records, and his personal statements. Neither he nor his representative has indicated, and the record does not otherwise suggest, any additional existing evidence that is necessary to decide this claim that has not been obtained and is obtainable. Consequently, the Board finds that VA has fulfilled its duties to notify and assist him with his claim. Standard of Review After the evidence has been assembled, it is the Board's responsibility to evaluate the entire record. 38 U.S.C.A. § 7104(a) (West 2002). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102 (reasonable doubt to be resolved in the Veteran's favor). In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the Court explained that "a Veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. Governing Statutes, Regulations and Case Law Service connection is granted for disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service in the line of duty. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. §§ 3.303(a), 3.306 (2012). 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. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then generally a showing of continuity of symptoms after service is required to support the claim. 38 C.F.R. § 3.303(b). Service connection may be granted for any disease diagnosed after discharge, when the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303(d). Establishing entitlement to service connection generally requires having: (1) competent and credible evidence confirming the Veteran has the alleged disability or, at the very least, showing he has at some point since the filing of his claim; (2) competent and credible evidence of in-service incurrence or aggravation of a relevant disease or an injury; and (3) competent and credible evidence of an etiological link or correlation between the disease or injury in service and the disability now claimed - the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Certain diseases like arthritis are considered chronic, per se, and therefore will be presumed to have been incurred in service if manifested to a compensable degree (generally meaning to at least 10-percent disabling) within one year after service. This presumption, however, is rebuttable by affirmative evidence to the contrary. See 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). The United States Court of Appeals for the Federal Circuit (Federal Circuit Court) recently held in Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013), however, that the notion of showing continuity of symptomatology since service under 38 C.F.R. § 3.303(b) to alternatively establish the required nexus or correlation between the disability now claimed and a disease or an injury or an event during service only applies to conditions like arthritis that are specifically denoted as "chronic" in 38 C.F.R. § 3.309(a). As previously acknowledged, including in the Board's September 2012 remand, the Veteran served in the Southwest Asia Theater of Operations during the Persian Gulf War. Therefore, service connection also may be established on an alternative presumptive basis under 38 U.S.C.A. § 1117 and 38 C.F.R. § 3.317. Under this statute and regulation, service connection may be warranted for a Persian Gulf War Veteran who exhibits objective indications of a qualifying chronic disability that became manifest during active military, naval or air service in the Southwest Asia Theater of Operations during the Persian Gulf War or to a degree of 10 percent or more not later than December 31, 2016. See 38 C.F.R. § 3.317(a)(1). For purposes of 38 C.F.R. § 3.317, there are three types of qualifying chronic disabilities: (1) an undiagnosed illness; (2) a medically unexplained chronic multi-symptom illness; and (3) a diagnosed illness that the Secretary of VA determines in regulations prescribed under 38 U.S.C.A 1117(d) warrants a presumption of service connection. An undiagnosed illness is defined as a condition that by history, physical examination and laboratory tests cannot be attributed to a known clinical diagnosis. In the case of claims based on undiagnosed illness under 38 U.S.C.A. § 1117 and 38 C.F.R. § 3.117, unlike those for "direct service connection," there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Gutierrez v. Principi, 19 Vet. App. 1, 8-9. Further, lay persons are competent to report objective signs of illness. Id. To determine whether the undiagnosed illness is manifested to a degree of 10 percent or more the condition must be rated by analogy to a disease or an injury in which the functions affected, anatomical location or symptomatology are similar. See 38 C.F.R. § 3.317(a)(5); see also Stankevich v. Nicholson, 19 Vet. App. 470 (2006). But consider also that for claims, as here, received after June 9, 1998, disability shall not be considered to have resulted from personal injury suffered or disease contracted in the line of duty in the active military service on the basis that it resulted from injury or disease attributable to the use of tobacco products by the Veteran during service. 38 U.S.C.A. § 1103(a); 38 C.F.R. § 3.300(a). Competency of evidence differs from its weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, whereas credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67 (1997); Layno v. Brown, 6 Vet. App. 465 (1994); Cartwright v. Derwinski, 2 Vet. App. 24 (1991) (although interest may affect the credibility of testimony, it does not affect competency to testify). A Veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to him through his senses. See Layno, 6 Vet. App. 465. The Board is charged with the duty to assess the credibility and weight given to evidence. Wensch v. Principi, 15 Vet. App. 362, 367 (2001); Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. Caluza v. Brown, 7 Vet. App. 498 (1995). 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. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). Generally, the degree of probative value that may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of the Veteran's claims file. Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Mere review of the claims file, though often important, is not determinative of an opinion's probative value, however, since a reliable history of the disability may be obtained in other ways, such as by the examiner having personally treated the Veteran over a number of years. Neives-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005) (rejecting medical opinions that did not indicate whether the physicians actually had examined the Veteran, did not provide the extent of any examination, and did not provide any supporting clinical data). The Court has held that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). Medical evidence that is speculative, general or inconclusive in nature cannot support a claim. Obert v. Brown, 5 Vet. App. 30, 33 (1993); see also Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996); Libertine v. Brown, 9 Vet. App. 521, 523 (1996). A physician's statement framed in terms such as "may" or "could" is not probative. See Warren v. Brown, 6 Vet. App. 4, 6 (1993). A significant factor to be considered for any opinion is the accuracy of the factual predicate, regardless of whether the information supporting the opinion is obtained by review of medical records or lay reports of injury, symptoms and/or treatment. See Harris v. West, 203 F.3d 1347, 1350-51 (Fed. Cir. 2000) (examiner opinion based on accurate lay history deemed competent medical evidence in support of the claim); Kowalski v. Nicholson, 19 Vet. App. 171, 177 (2005) (holding that a medical opinion cannot be disregarded solely on the rationale that it was based on history given by the Veteran). As the Court reaffirmed in Coburn v. Nicholson, 19 Vet. App. 427 (2006), reliance on a Veteran's statements renders a medical report not credible only if the Board rejects the statements of the Veteran as lacking credibility. But see, too, Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that the Board may reject a medical opinion based on an inaccurate factual basis). In deciding this claim, the Board has reviewed all of the evidence in the Veteran's claims file, both his physical claims file and electronic ("Virtual VA") claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by him or obtained on his behalf be discussed in exhaustive detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Discussion As already conceded, the Veteran's military personnel records confirm he served in the Southwest Asia Theater of Operations during the Persian Gulf War and, as such, service connection may be established on a presumptive basis under 38 U.S.C.A. § 1117 and 38 C.F.R. § 3.317. He claims entitlement to service connection for CFS, including as a qualifying chronic disability under this statute and regulation and encompassing complaints of achy joints, sore/weak muscles, recurrent rash of groin and neck, chronic bronchitis with coughing and shortness of breath, and low-grade fever, chills at sunset, tender glands, and a general feeling of not being well. In its October 2010 remand, the Board inquired as to whether there were objective indications he had achy joints, sore/weak muscles, recurrent rash of groin and neck, chronic bronchitis with coughing and shortness of breath, and low-grade fever, chills at sunset, tender glands, and a general feeling of not being well, and, if so, whether any of these symptoms were due to a specific disease entity or pathology. In response, the VA compensation examiner that evaluated the Veteran in January 2011 confirmed there were objective indications he had achy joints - but due to degenerative joint disease (DJD, i.e., arthritis) at multiple sites; recurrent rash of his groin and neck was due to resolving tinea cruris of the left groin; and chronic bronchitis with coughing and shortness of breath was due to mild obstructive ventilatory defect. The examiner further explained that the Veteran did not meet the diagnostic criteria for CFS, and that the fatigue and general feeling of not being well of which he had complained was most likely due instead to his PTSD, back disability, DJD at multiple sites, and chronic prescription medication use, including hydrocodone for his back disability and other medication for his PTSD and sleep impairment. The examiner went on to note that there were no objective indications the Veteran had sore or weak muscles, low-grade fever, chills at sunset, or tender glands. Because there was no objective evidence of sore or weak muscles, low-grade fever, chills at sunset, or tender glands, these symptoms need not be further discussed. Additionally, CFS need not be further discussed, as this alleged disability also is not shown to be present. The most fundamental requirement for any claim for service connection is that the Veteran must have proof he has the condition claimed. See Degmetich v. Brown, 8 Vet. App. 208 (1995); 104 F.3d 1328 (1997) (indicating VA compensation only may be awarded to an applicant who has disability existing on the date of application, not for past disability); but see, too, McClain v. Nicholson, 21 Vet. App. 319 (2007) (further clarifying that this requirement of current disability is satisfied when the claimant has the disability at the time the claim for VA disability compensation is filed or during the pendency of the claim and that a claimant may be granted service connection even though the disability resolves prior to VA's adjudication of the claim). Congress has specifically limited entitlement for service-connected disease or injury to cases where such incidents have resulted in actual disability. Brammer v. Derwinski, 3 Vet. App. 223 (1992); Rabideau v. Derwinski, 2 Vet. App. 141 (1992); Gilpin v. Brown, 155 F.3d 1353 (Fed. Cir. 1998). A current disability means a disability shown by competent and credible evidence to exist. Chelte v. Brown, 10 Vet. App. 268 (1997). There is no such indication in this particular instance, however, at least not as concerning the components of this claim mentioned. As for the rest of the reported symptomatology, there were objective indications of these complained about symptoms, but these symptoms were attributed to specific disease entities or pathologies rather than manifestations of an undiagnosed illness; thus, further consideration of a qualifying chronic disability under 38 U.S.C.A. § 1117 and 38 C.F.R. § 3.317 is not required. In essence, as to those symptoms, there is no suggestion they represent an undiagnosed illness, a medically unexplained chronic multi-symptom illness, or a diagnosed illness that the Secretary of VA determines in regulations prescribed under 38 U.S.C.A 1117(d) warrants a presumption of service connection. Moreover, as there were no objective indications of sore or weak muscles, low-grade fever, chills at sunset, or tender glands, the Veteran has not met his threshold preliminary burden of proof concerning these claimed symptoms, inasmuch as he has not shown he actually has them. Hence, further inquiry as to their etiology is not required, especially insofar as any potential attribution to his military service. See Brammer, supra. In cases where a Veteran applies for service connection under 38 C.F.R. § 3.317, but is found to have a disability attributable to a known rather than unknown diagnosis, further consideration under the direct service-connection provisions of 38 U.S.C.A. § 1110 is nevertheless warranted. So service connection may be established either by showing direct service incurrence or aggravation or by using applicable presumptions, if available. See Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). The Veteran's complaints of achy joints have been attributed to DJD (arthritis) of multiple joints. He is already in receipt of service connection for a low back disability and for a right wrist disability. As such, these joints will not be discussed. Rather, the Board will focus instead on the other joints of which he has complained. On VA examination in January 2011, he reported pain in his elbows, knees, hips, ankles, and shoulders. X-rays revealed minimal osteoarthritic changes of his knees bilaterally, normal hips, an old left shoulder fracture and moderate right shoulder osteoarthritic changes, and normal elbows. No X-rays of his ankles were taken, but only apparently because there was no suggestion of disability. The examiner diagnosed minimum osteoarthritic changes of the knees, left shoulder DJD with evidence of an old fracture, moderate osteoarthritic changes of the right shoulder, bilateral hip pain, and right elbow pain that was a residual of the service-connected right wrist disability. The examiner rendered no diagnoses regarding the left elbow and ankles. But ultimately, the examiner determined the Veteran's joint symptoms were unrelated to his service in the Persian Gulf War during 1990 and 1991. Rather, she explained that his joint symptoms instead were most likely related to DJD secondary to wear and tear. As well, she indicated that although there was no DJD of the hips, it was common for someone with a back disability such as the Veteran's to experience pain in the hips. The right elbow pain was attributable to the service-connected right wrist disability. The STRs do not reflect any findings concerning these joints other than the ankles. Specifically, although the Veteran may have voiced general complaints about joints, further examination of the STRs reveals that no findings were ever rendered regarding the particular joints at issue other than his ankles. He reported bilateral ankle pain in October 2003 that had begun spontaneously some three months earlier. He denied any precipitating injury. Then and in November 2003 ankle pain and instability were diagnosed. But he made no further complaints regarding his ankles during the remainder of his service, and in a November 2005 report of medical history he did not report any symptoms referable to his ankles. Indeed, he marked impaired use of his arms, legs, hands, or feet, but the examiner indicated the Veteran was in actuality referring just to his wrists. The Board consequently finds that no disability of the ankles was present when he filed his claim for benefits under 38 C.F.R. § 3.317 in May 2005. As stated, only symptoms associated with the ankles were apparent in service. No actual diagnosis as to the source of the symptoms was rendered, and he denied an inciting injury to his ankles. In November 2005 he reported no symptoms associated with his ankles when recounting his relevant medical history. And during his VA examination in January 2011, he reported bilateral ankle pain, but the examiner rendered no diagnosis regarding the ankles despite the Veteran's reports of symptoms such as pain, giving way, stiffness, and tenderness. Symptoms alone do not constitute disabilities for VA compensation purposes. See generally Sanchez-Benitez v. Principi, 259 F.3d 1356 (Fed. Cir. 2001) (holding that "[p]ain alone, 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"). Thus, the Board finds that the Veteran does not suffer from a disability of either ankle, much less as a result or consequence of his military service. Despite his complaints of pain, which has been attributed to his service-connected low back disability, his hips have been found to be clinically normal. Thus, no disability of the hips is shown to be present, either. If the seeming pain in his hips is in fact associated with his service-connected low back disability, as the VA compensation examiner suggested may be the case, then this pain will be compensated in the rating for the low back disability, rather than separately. As well, the elbows have been found to be clinically normal, and right elbow pain has been attributed to the service-connected right wrist disability. The Board is aware that a February 1993 VA examiner diagnosed idiocondylitis or epicondylitis of both elbows at the conclusion of that earlier evaluation. But this condition appears to have resolved because it has not been noted at any other time in the record, including in the STRs from the Veteran's second period of service or even during his post-service VA compensation examination in January 2011. The granting of service connection presupposes the presence of a current disability. Brammer, supra. Because no disabilities of the ankles, hips, or elbows is present, service connection for disabilities of these joints necessarily cannot be granted. Id.; 38 C.F.R. § 3.303. The January 2011 VA examiner diagnosed arthritic disabilities of the knees and shoulders. There is no indication these disabilities were incurred in service, as the STRs are unremarkable as concerning these particular joints. Furthermore, there is no indication that arthritis of these joints incepted within a year of the Veteran's separation from either period of active duty service, certainly not to the required minimum compensable degree of at least 10-percent disabling. 38 C.F.R. § 4.71a, Diagnostic Codes 5003 and 5010. Degenerative changes of the right shoulder were first diagnosed in February 1993, more than a year after his separation from his first period of active duty. There is no record of a diagnosis of arthritis of these joints (other than the right shoulder) until January 2011, more than five years after his separation from his second period of active duty. As such, service connection is not warranted presumptively based on incurrence within a year of service separation. He also had service in the Tennessee Army National Guard. Active military, naval, or air service includes not only active duty (AD) but also any period of active duty for training (ADT) during which the individual concerned was disabled or died from a disease or an injury incurred in or aggravated in the line of duty, and any period of inactive duty training (IADT) during which the individual concerned was disabled or died from an injury - though not also disease - incurred in or aggravated in the line of duty, also when a cardiac arrest or cerebrovascular accident occurs during such training. 38 U.S.C.A. § 101(21), (24) (West 2002); 38 C.F.R. § 3.6(a), (d) (2012). Reserve and National Guard service generally means ADT and IADT. ADT 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); 38 C.F.R. § 3.6(c). 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. IADT 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); 38 C.F.R. § 3.6(d). Basically, this refers to the twelve four-hour weekend drills that each Reservist or National Guardsman must perform each year and is often referred to as "weekend warrior" training. These drills are deemed to be part-time training. So to establish status as a "Veteran" based upon a period of ADT, a claimant must establish that he or she was disabled from disease or injury incurred or aggravated in the line of duty during that period of ADT. 38 C.F.R. § 3.1(a), (d); Harris v. West, 13 Vet. App. 509, 511 (2000); Paulson v. Brown, 7 Vet. App. 466, 470 (1995). The fact that a claimant has established status as a "Veteran" for purposes of other periods of service (e.g., AD) does not obviate the need for him or her to establish that he or she is also a "Veteran" for purposes of the period of ADT where the claim for benefits is premised on that period of ADT. Mercado-Martinez v. West, 11 Vet. App. 415, 419 (1998). Similarly, in order for a claimant to achieve "Veteran" status and be eligible for service connection for disability claimed during his or her inactive service, the record must establish that he or she was disabled from an injury, but not disease, incurred or aggravated during IADT. Id; see also Paulson v. Brown, 7 Vet. App. 466, 470 (1995); Biggins v. Derwinski, 1 Vet. App. 474, 478 (1991). Generally, an individual who has only Reserve or National Guard service (ADT or IADT with no AD) is not a Veteran as legally defined. In the service connection context, for example, this means the presumption of soundness upon entry into service and the presumptive service connection provisions of 38 C.F.R. § 3.307 , applicable to AD, do not apply to ADT or IADT. The same is true of the presumption of aggravation. See Smith v. Shinseki, 24 Vet. App. 40 (2010); Biggins v. Derwinski, 1 Vet. App. 474, 476-78 (1991). Thus, service connection may be granted for a disability resulting from a disease or an injury incurred or aggravated while performing ADT, or from an injury incurred or aggravated while performing IADT. 38 U.S.C.A. §§ 101(24), 106, 1131 (West 2002). National Guard duty is distinguishable from other Reserve service, however, in that a member of the National Guard may be called to duty by the governor of their state. "[M]embers of the National Guard only serve the federal military when they are formally called into the military service of the United States[; a]t all other times, National Guard members serve solely as members of the State militia under the command of a state governor." Allen v. Nicholson, 21 Vet. App. 54, 57 (2007). "Therefore, to have basic eligibility for Veterans benefits based on a period of duty as a member of a state National Guard, a National Guardsman must have been ordered into Federal service by the President of the United States, see 10 U.S.C. § 12401, or must have performed "full-time duty" under the provisions of 32 U.S.C. §§ 316, 502, 503, 504, or 505. Id. There is no suggestion this is the situation at hand. Finally, because there is a gap of years between separation from either period of active duty and a diagnosis of arthritis regarding all of the relevant joints herein, service connection for arthritic changes to the shoulder and knee joints cannot be granted based on continuity of symptomatology. Arthritis is not a "simple" condition, so it must be objectively confirmed by X-ray. See 38 C.F.R. § 4.71a, Diagnostic Codes 5003 and 5010. The Veteran's mere lay assertions of its existence, then, are insufficient to conclude he had it within the required one-year grace period following the conclusion of his AD service. As observed by the Federal Circuit Court, lay evidence must "demonstrate some competence." See King v. Shinseki (Fed. Cir. 2012) (citing 38 U.S.C.A. § 5107(b) and 38 C.F.R. § 3.307(b)) (internal quotation marks omitted). The Board may therefore discount the probative value of lay evidence if it finds such evidence not to be competent. See id.; see also Layno v. Brown, 6 Vet. App. 465, 469 (1994) (holding that in order for testimony to be probative of any fact, the witness must be competent to testify as to the facts under consideration). However, the Board may not "categorically" require medical evidence or disregard lay evidence without first assessing its competence. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (holding that it was error in a cause-of-death claim to find "categorically" that a medical opinion was required to prove a nexus between the Veteran's service-connected mental disorder and his drowning death, and likewise to reject categorically the claimant's testimony on this issue as not competent simply because she was a lay person); see also Kahana v. Shinseki, 24 Vet. App. 428, 434 (2011) (holding that the Board erred in categorically rejecting lay evidence without analyzing and weighing it). Importantly, lay statements submitted by or on behalf of a claimant can be competent with respect to both the diagnosis and the etiology or cause of a disability, but this is entirely dependent on the specific type of disability at issue. See Davidson, 581 F.3d at 1316. Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. See 38 C.F.R. § 3.159(a)(2); Layno, 6 Vet. App. at 469 (holding that lay testimony is not competent to prove that which would require specialized knowledge, training, or medical expertise). Lay evidence is competent if it is provided by a person who has first-hand knowledge of facts or circumstances, or conveys matters that can be observed and described by a lay person. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005) (holding that appellant was competent to testify as to factual matters of which he had first-hand knowledge, such as experiencing pain in his right hip and thigh in service, reporting to sick call, being placed on limited duty, and undergoing physical therapy). For example, the Court has held that a lay person is competent to diagnose a disease with "unique and readily identifiable features" such as varicose veins. Barr v. Nicholson, 21 Vet. App. 303, 309 (2007). Similarly, the Court has found a lay person competent to identify tinnitus and flat feet, which are disorders that can be identified based on lay observation alone. See Charles v. Principi, 16 Vet. App. 370 (2002) (tinnitus); Falzone v. Brown, 8 Vet. App. 398 (1995) (flatfeet). However, lay testimony is not competent with respect to determinations that are "medical in nature" or require medical knowledge due to their complexity. See Barr, 21 Vet. App. at 309. For example, the Court held that a claimant was not competent to determine whether he had rheumatic fever, which was a more medically complex condition. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). See also Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed. Cir. 2010) (recognizing that in some cases lay testimony "falls short" in proving an issue that requires expert medical knowledge); Waters v. Shinseki, 601 F.3d 1274, 1278 (Fed. Cir. 2010) (concluding that a Veteran's lay belief that his schizophrenia had aggravated his diabetes and hypertension was not of sufficient weight to trigger the Secretary's duty to seek a medical opinion on the issue). The Federal Circuit Court has held that lay evidence may be competent and sufficient to establish a diagnosis of a condition in the following circumstances: (1) when the condition is simple, such as a broken leg, as opposed to when the condition is more complex, such as a form of cancer; (2) when the layperson is reporting a contemporaneous medical diagnosis, or; (3) when lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F. 3d 1372, 1377 & n4 (Fed. Cir. 2007). Competent medical evidence, as distinguished from lay evidence, is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. 38 C.F.R. § 3.159(a)(1). Competent medical evidence may include statements conveying sound medical principles found in medical treatises. Id. It would also include statements contained in authoritative writings such as medical and scientific articles and research reports or analyses. Id. Here then, in sum, service connection cannot be granted based on incurrence in service, continuity of symptomatology, or presumptively based on incurrence within a year of separation for a chronic disability. 38 C.F.R. §§ 3.303(a) and (b); 3.397, 3.309(a). Because service connection for disabilities of these joints cannot be granted based on incurrence in service, continuity of symptomatology, or presumptively based on incurrence within a year of separation for a chronic disability, the only other means of establishing entitlement to service connection is if the evidence reflects that arthritis of the relevant joints is otherwise related to service. The Veteran is not competent to opine regarding the etiology of his DJD of multiple joints. See again Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose complex disabilities such as cancer). Moreover, he does not assert that his DJD of multiple joints is directly related to his service. The only competent evidence in this regard is the January 2011 VA examiner's opinion indicating that, other than the right shoulder arthritis that is injury related, the Veteran's arthritic changes are due to the wear and tear that happens over time. Based on this opinion, especially since there is no evidence of a right shoulder injury in service, there is no competent and credible evidence linking arthritis of any of the relevant joints to the Veteran's service. Thus, service connection for arthritis of multiple joints is not warranted. 38 C.F.R. § 3.303(d). As to the Veteran's skin, his STRs contain no complaints or notations related to his skin. In a January 1990 report of medical history, he expressly denied skin diseases. In the corresponding medical examination report, all bodily systems, to include the skin, were marked as normal. In an April 1991 report of medical history, he again denied any skin problems. The corresponding medical examination report reflected normal skin also. During a VA general medical examination in February 1993, performed subsequent to his first period of active duty and prior to his second, he complained of follicular eruptions on his back and neck that came and went; however, on objective physical examination, only folliculitis of the anterior axillary, the armpit, and dermatophytosis of the fingers were observed. There was no evidence of a recurrent rash of the groin and neck at that time. In a February 1994 report of medical history completed by the Veteran, he denied skin diseases. The corresponding medical examination report indicated that his skin was normal. In a June 2004 post-deployment report, he again expressly denied any skin diseases. In September 2004, a VA physician observed the Veteran's skin did not have rashes, lesions, induration, or ulcerations. In May 2005, the Veteran indicated he had experienced recurrent rashes in his neck and groin area. In a November 2005 report of medical history, he denied skin diseases. The corresponding medical examination report indicated the presence of seborrheic keratosis and actinic keratosis. The examiner made no further remarks regarding this diagnosis. In August 2006, the Veteran indicated the "rash had been gone" and that it took six or seven days to clear. During a VA Persian Gulf War protocol examination in July 2008, the Veteran indicated intermittent groin rashes since 1992. The diagnosis was history of rash, resolved. In December 2008, three skin tags were excised from the Veteran's back. An August 2009 VA active-problem list included seborrheic keratosis. On another occasion in August 2009, a review of systems indicated a rash. In October 2009, there was a boil in the left axillary area. On September 2010, probable squamous cell cancer versus actinic keratosis was diagnosed. During his January 2011 VA compensation examination, the Veteran reported an intermittent neck rash that he had noticed after returning home from the Persian Gulf War. As well, he indicated that he had first noticed a rash in his groin when he was in Desert Storm and that he was given "lotions and powders" in the clinic and told the rash resulted from sweating. He had that sort of rash "quite often." Objectively, the examiner indicated there was no neck rash on the day of that examination. However, there were signs of seborrheic dermatitis of the face and scalp with slight erythema. The right groin was without any abnormal physical findings. The left inguinal area had a reddish pink color consistent with resolving tinea cruris. After additional VA examination in October 2012, the VA examiner opined that the Veteran's claimed rash was unrelated to his service. The examiner based the opinion on an apparently exhaustive review of the record, as clear from the summary of the relevant medical history. As to seborrehic dermatitis, the examiner indicated that it was unrelated to the Veteran's service. First, she noted that seborrehic dermatitis was not noted in the STRs. Next, she indicated that the fungus Malassezia was a component of the normal life forms present in oily secretions. As for the tinea cruris, she opined that it too was unrelated to service. She explained that the condition was not noted in the STRs and that it was caused by heavy sweating, obesity, failure to launder undergarments, and/or atopic dermatitis. As to the latter, she observed there was no indication that the Veteran had ever suffered from atopic dermatitis. The Board finds this evidence does not warrant the granting of service connection for any sort of rash or skin disability. The Board recognizes that the Veteran is competent to report the presence of rashes, as such manifestations are readily apparent through the senses. Layno, supra. The Board, however, does not find credible his assertions of recurrent rashes since 1992, as he explicitly denied skin problems in all reports of medical history dated after 1992 - including in February 1994. See Wensch, supra; see also Curry v. Brown, 7 Vet. App. 59, 68 (1994) (noting that contemporaneous evidence has greater probative value than history as reported by a Veteran). Although the Board cannot reject a claimant's statements merely because he is an interested party, the claimant's interest may affect the credibility of his testimony when considered in light of the other factors. See Cartright, 2 Vet. App. at 25; accord Buchanan, 451 F.3d at 1337 (holding that "the Board, as fact finder, is obligated to, and fully justified in, determining whether lay evidence is credible in and of itself, i.e., because of possible bias . . . ."). This is especially true when considering that may of his prior examinations were in the course of his earlier evaluation and treatment, when there was no incentive to fabricate information for personal gain, financial or otherwise. Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive proper care). See also Harvey v. Brown, 6 Vet. App. 390, 394 (1994) (upholding a Board decision assigning more probative value to a contemporaneous medical record report of cause of a fall than subsequent lay statements asserting different etiology); Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (upholding Board decision giving higher probative value to a contemporaneous letter the Veteran wrote during treatment than to his subsequent assertion years later). Furthermore, despite complaints of follicular eruptions of the back and neck during his VA examination in February 1993, the examiner observed no such eruptions on objective physical examination; only folliculitis of the anterior axillary, the armpit, and dermatophytosis of the fingers were observed. There was no evidence of a recurrent rash at that time. Next, the Board does not find credible the Veteran's May 2005 assertions regarding recurrent rashes of the neck and groin for a number of reasons. See Jefferson v. Principi, 271 F.3d 1072, 1076 (Fed. Cir. 2001) (recognizing the Board's inherent fact-finding ability). First, the February 1993 VA examination did not reveal a rash of the neck or groin. He also expressly denied skin diseases in a June 2004 report of medical history, and because a VA examiner in September 2004 found no rashes or other abnormal skin manifestations. In a February 1994 report of medical history completed by the Veteran, he again denied skin diseases. The corresponding medical examination report indicated that his skin was normal. In a June 2004 post-deployment report, he yet again expressly denied skin diseases. In September 2004, a VA physician indicated the skin was without rashes, lesions, induration, or ulcerations. Because the May 2005 statement differs markedly from previous evidence, including very recent statements, the Board cannot accept as true a divergent May 2005 statement. Id.; see again also Harvey v. Brown, 6 Vet. App. 390, 394 (1994) (upholding a Board decision assigning more probative value to a contemporaneous medical record report of cause of a fall than subsequent lay statements asserting different etiology). The Board emphasizes that, in November 2005, in a report of medical history, the Veteran unequivocally denied the presence of skin problems. The November 2005 assertions bolster the Board's finding that the May 2005 statement lacks credibility. In November 2005 and since, several skin conditions were diagnosed. These include seborrheic keratosis, actinic keratosis, basal cell cancer versus actinic keratosis, a boil, and skin tags. There is no indication of these conditions in service or close in time to service. As to rashes, specifically, there is evidence of treatment in 2006 and since. While the Veteran is competent to report symptoms, the Board already has determined that the history of rashes that he provided lacks credibility, especially given his prior intervening denials of their presence. Most recently two skin conditions were noted, seborrheic dermatitis of the face and scalp and resolving tinea cruris of the groin. The Veteran has not alleged that seborrehic dermatitis is related to his service. Indeed, a comprehensive review of the record fails to reveal complaints relevant to his face or scalp. Moreover, the October 2012 VA examiner found that seborrehic dermatitis was unrelated to the Veteran's service because the condition was not shown in service and because it occurred as a result of fungal yeast forms that normally reside on the skin. As to tinea cruris, the examiner opined indicated that it too was unrelated to the Veteran's service because it was not shown therein and because it was likely due to a host of other factors such as sweating. Sweating is not exclusive to military service. Under normal circumstances a medical opinion that ignores the Veteran's assertions regarding in-service incurrence and bases the opinion on a lack of evidence in the STRs is inadequate. See Dalton v. Nicholson, 21 Vet. App. 23 (2007) (an examination was inadequate where the examiner did not comment on the Veteran's report of in-service injury and instead relied on the absence of evidence in the Veteran's STRs to provide a negative opinion). Here, though, the examiner's lack of attention to the Veteran's assertions as to in-service incurrence is immaterial given that the Board does not find the Veteran's assertions of a rash-like disability during his Gulf War service or since 1992 credible. Moreover, an opinion has to be viewed in its full context and not characterized solely by the medical professional's choice of words. See Lee v. Brown, 10 Vet. App. 336, 338 (1997). In short, as apparent from the foregoing discussion, a rash-like skin disability is unrelated to service or any incident therein. There is no evidence of rash or any skin disability during any period of active duty, and there is no competent and credible evidence linking any present rash-like disability to service. As such, direct service connection for a rash-like skin disability is denied. 38 C.F.R. § 3.303. As to the respiratory matter, in a January 1990 report of medical history prior to the Veteran's first period of service, he denied shortness of breath. In a report of medical history completed in April 1991, just two months prior to the termination of his first period of active duty, he indicated shortness of breath. However, in the corresponding report of medical history, the examiner found all bodily systems to be normal. During the February 1993 VA general medical examination, the Veteran indicated that his employment history included truck driving and construction and work as a tree surgeon from 1973 to 1993. Objectively, his chest was clear to auscultation and percussion with normal excursion. An X-ray of his chest was within normal limits. In a February 1994 report of medical history, he again indicated shortness of breath. However the corresponding medical examination report indicated his lungs continued to be normal. In a post-deployment medical assessment form completed in June 2004, he denied shortness of breath and wheezing. A September 2004 VA progress note indicated that chest diameter was normal and that there was no rales, ronchi, or wheezes. Air movement was good, and there was no dullness to percussion. In a November 2005 report of medical history, he crossed out shortness of breath and marked "NO" in the circle corresponding to shortness of breath. As to chronic cough, the examiner indicated there had been no recent chest X-ray according to the Veteran. In a corresponding medical examination report, the examiner indicated scattered wheezes and coarse breath sounds. In February 2006, the Veteran sought treatment for flu-like symptoms with coughing. He denied difficulty breathing and chest pain. In June 2006, he presented with complaints of rhinitis and a productive cough with green sputum. He denied shortness of breath. In February 2008, he appeared for a follow-up visit for an evaluation of an upper chest respiratory infection. There was shortness of breath due to the upper respiratory infection. There was no wheezing. An upper respiratory infection and tobacco use disorder were assessed. A May 2008 VA medical problem list included tobacco use disorder. During his July 2008 VA Persian Gulf War examination, he complained of chronic bronchitis with coughing and shortness of breath including wheezing. On objective examination of his lungs, auscultation and percussion were normal. He did not report for pulmonary function testing (PFT), and no diagnosis regarding his respiratory system was rendered. August 2009 VA progress notes revealed wheezing and shortness of breath. An August 2009 progress note listed a diagnosis of COPD and indicated he had a one and a half pack a day smoking history for 30 years. A July 2010 VA progress note indicated his lungs were clear to auscultation. There were no rales, ronchi, or wheezing. A September 2010 VA progress note reflects complaints of a productive cough. He denied shortness of breath, chest pain, and dizziness. The examiner indicated that, despite repeated instructions to stop smoking, the Veteran had not. During a January 2011 VA medical examination, the Veteran reported that his shortness of breath had begun four or five years earlier. He thought he had bronchitis but never sought treatment for that condition. Symptoms included clear productive secretions. He indicated that he had begun smoking a pack a day at the age of 20. He coughed daily. The cough tended to be productive early in the day and nonproductive as the day progressed. There was a history of coughing, wheezing, and dyspnea. The examiner indicated that, comparing a then current chest X-ray study to an earlier February 2008 X-ray study, the study was entirely normal. In an addendum, the examiner indicated that PFT completed in February 2011 had revealed a mild obstructive ventilatory defect and a mild decrease in diffusion capacity. The diagnosis was mild obstructive ventilatory defect entailing shortness of breath. The examiner opined that the Veteran's symptoms were unrelated to his service in the Persian Gulf War. The examiner explained that cigarette smoking was the primary cause of COPD, also noting the Veteran had smoked for 33 years and had spent only nine months in the Persian Gulf War. Thus, because he reported that shortness of breath had begun four or five years earlier and because he had smoked for far longer than he spent in the Persian Gulf War, exposure to pollutants during the Persian Gulf War did not likely cause his respiratory disorder. The examiner indicated that exposure to air pollution and nearby cigarette smoke also worsens COPD and might cause COPD. The examiner ultimately attributed the Veteran's COPD to his history of chronic smoking rather than to anything that had occurred during his military service, including while stationed in Saudi Arabia during Operation Desert Storm. For claims, as here, received after June 9, 1998, disability shall not be considered to have resulted from personal injury suffered or disease contracted in the line of duty in the active military service on the basis that it resulted from injury or disease attributable to the use of tobacco products by the Veteran during service. 38 U.S.C.A. § 1103(a); 38 C.F.R. § 3.300(a). The examiner, however, did not consider the Veteran's assertions of shortness of breath much earlier to include in 1991. The failure to consider the entirety of his medical history rendered the examiner's opinion non probative. See Reonal v. Brown, 5 Vet. App. 458, 460-61 (1993) (holding that medical opinions based on an incomplete or inaccurate factual premise are not probative). That notwithstanding, in a subsequent October 2012 addendum opinion, the examiner again indicated the Veteran's respiratory condition was unrelated to his military service or any event therein. The examiner explained that the Veteran had three risk factors for his respiratory condition. First, he was exposed to irritants/pollution during the Persian Gulf War. Second, he was exposed to dust in connection with his work as a tree trimmer for 20 years. The third risk factor was a 30-year history of tobacco use. The examiner explained that the Veteran's 30-year history of tobacco use outweighed exposure to irritants in the Persian Gulf War. In rendering the opinion, the examiner reviewed the entirety of the relevant medical history, including the above-mentioned reports of shortness of breath in 1991. While the Veteran voiced complaints of shortness of breath in 1991 during a period of active duty, his history of shortness of breath and respiratory complaints has been intermittent and inconsistent. A diagnosis associated with the symptoms, moreover, was not rendered until many years later. As stated, symptoms without an associated diagnosis do not constitute disabilities for which service connection may be granted. Sanchez-Benitez, supra. The Veteran currently suffers from a mild obstructive ventilatory defect. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), the specific issue in this case, which involves the origins of a pulmonary disorder, falls outside the realm of the common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer)." Thus, the Veteran's assertions regarding the etiology of his respiratory disorder do not constitute competent evidence, and they carry no probative weight. The January 2011 VA examiner's failure to consider the entirety of the Veteran's medical history rendered that examiner's opinion non probative. See Reonal, 5 Vet. App. at, 460-61 (holding that medical opinions based on an incomplete or inaccurate factual premise are not probative). That, however, prompted the Board to obtain the additional medical nexus opinion, which subsequently was provided in October 2012. This additional opinion was based on all of the relevant evidence of record, including from 1991, and the examiner explained the findings and conclusions satisfactorily. The Board finds, therefore, that the October 2012 VA opinion is both competent and probative of the issue at hand - that being the causation of the Veteran's respiratory disorder. Nieves-Rodriguez, 22 Vet. App. at 302-04; Prejean, 13 Vet. App. at 448-9 (holding that factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion). According to the October 2012 VA opinion, the Veteran's current pulmonary symptoms are due to his decades-long history of tobacco use. Because he filed his claim for benefits after June 9, 1998, a disability caused by tobacco use whether in service or otherwise is not subject to service connection. Thus, service connection for his mild obstructive pulmonary defect cannot be granted either directly or presumptively because it is most likely the result of his chronic smoking history. 38 U.S.C.A. § 1103(a); 38 C.F.R. § 3.300(a). As fully apparent from the foregoing discussion, service connection for the claimed aching joints, skin rash, and respiratory disorder cannot be granted under 38 C.F.R. § 3.317. Furthermore, service connection is not warranted either directly or based on any other presumption. 38 C.F.R. §§ 3.303, 3.307, 3.309. As such, the claim herein is denied. The Board has considered the provisions of 38 U.S.C.A. § 5107(b) and 38 C.F.R. § 3.102, but there is not such a state of approximate balance of the positive evidence with the negative evidence to otherwise warrant a more favorable decision. ORDER Service connection for CFS, including as a qualifying chronic disability under 38 C.F.R. § 3.317 and encompassing complaints of achy joints, sore/weak muscles, recurrent rash of groin and neck, chronic bronchitis with coughing and shortness of breath, and low-grade fever, chills at sunset, tender glands, and a general feeling of not being well is denied. REMAND Additional VA opinions are needed prior to adjudicating the Veteran's remaining claim for a digestive disorder, diagnosed as GERD and previously claimed as stomach ulcers and esophagitis.. See Barr, 21 Vet. App. at 311 (holding that once VA undertakes the effort to provide an examination in a service-connected claim, even if not statutorily obligated to do so, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided). See, too, Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (indicating an opinion must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions). It appears the Veteran first reported a history of frequent indigestion during an examination in January 1990, so prior to his first tour of duty that began later that year in September 1990. He also complained of a history of frequent indigestion on examination in April 1991, during his first tour of duty, and in May 2003 and June 2004, during his second tour of duty. Subsequent to the conclusion of his second tour of duty, he complained of frequent indigestion in November 2005. On VA compensation examination in February 1992, so subsequent to his first period of active service and prior to his second period, he reported that his gastrointestinal symptoms had begun in April 1991, so during his first tour of duty. He was diagnosed at that time with active esophagitis. In Quirin v. Shinseki, 22 Vet. App. 390, 394, 396 (2009), the Court held that the presumption of soundness applies if a Veteran's condition was not noted at entry into service. The Court cited Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004), wherein the Federal Circuit Court had made clear that the only prerequisite for the application of the presumption of soundness is that the Veteran's entry examination have been free and clear of any noted disease or disabilities. Quirin, 22 Vet. App. at 396. In this circumstance, the burden then falls on the government to rebut this presumption of soundness with clear and unmistakable evidence that the Veteran's disability was both preexisting and not aggravated by his service or, if aggravated, it was not beyond the condition's natural progression. See 38 U.S.C.A. § 1111 (West 2002); VAOPGCPREC 3-2003 (July 16, 2003) and Wagner, 370 F.3d 1089, at 1096. A pre-existing disease will be considered to have been aggravated by active service where there is an increase in disability during service, unless there is a specific finding that the increase in disability is due to the natural progression of the disease. 38 U.S.C.A. § 1153 (West 2002); 38 C.F.R. § 3.306 (2012). In the Board's prior September 2012 remand, the Board noted that the Veteran's STRs had revealed that he did not undergo a physical examination prior to his tours of duty beginning in 1990 and 2003, respectively. The Board observed, therefore, that it must be presumed, at least initially, that he was in sound health when beginning those two periods of service. Quirin, 22 Vet. App. at 396. Therefore, while the February 2011 examiner had concluded the Veteran's symptoms had first begun in 1992, namely after his first tour of duty from 1990 to 1991, and that the symptoms he complained of during his second tour of duty from 2003 to 2004 were merely a continuation of his pre-existing problem that had developed in the interim, after his first tour of duty, the examiner did not apparently consider the medical evidence of record suggesting a possible earlier onset of relevant symptoms or render an opinion as to whether there is clear and unmistakable evidence the Veteran's disorder was both preexisting and not aggravated by either period of active service or, if aggravated, it was not beyond the condition's natural progression. See 38 U.S.C.A. § 1111; VAOPGCPREC 3-2003 (July 16, 2003) and Wagner, 370 F.3d 1089, at 1096. In its September 2012 remand, the Board asked the following: Forward the claims file to the examiner who performed the February 2011 VA compensation examination of the Veteran (or a suitable substitute if this individual is unavailable) for an addendum report and opinion addressing the etiology of the Veteran's digestive disorder, diagnosed as GERD. If the examiner determines that an additional VA compensation examination is required in order to fully respond to the Board's inquiries, so schedule the Veteran. (a) Considering the Veteran's January 1990 report of a history of frequent indigestion, did he clearly and unmistakably have a digestive disorder prior to beginning his first period of active service from September 1990 to June 1991? (b) If he did, is there also clear and unmistakable evidence this pre-existing condition was not aggravated beyond its natural progression during or by his first period of active military service from September 1990 to June 1991, including considering his April 1991 report of a history of frequent indigestion? (c) Else, considering the Veteran's April 1994 report of a history of frequent indigestion, did he clearly and unmistakably have a digestive disorder prior to beginning his second period of active service from January 2003 to July 2004? (d) If he did, is there also clear and unmistakable evidence this pre-existing condition was not aggravated beyond its natural progression during or by his second period of active military service from January 2003 to July 2004, including considering his May 2003 complaints of stomach pain and resultant diagnosis of dyspepsia, as well as his June 2004 report of a history of frequent indigestion? (e) If there is not this required clear and unmistakable evidence to satisfy this two-prong analysis, i.e., to establish the preexistence of the digestive disorder and that it was not aggravated during or by the Veteran's service beyond its natural progression, then also consider his reports of a history of frequent indigestion in April 1991, April 1994, June 2004, and November 2005, as well as his May 2003 complaints of stomach pain and resultant diagnosis of dyspepsia, in determining the likelihood (very likely, as likely as not, or unlikely) that any current digestive disorder, not just the GERD but also hiatal hernia, is related to or dates back to a period of active service, either the initial period from September 1990 to June 1991 or the later period from January 2003 to July 2004? In an October 2012 addendum, a VA physician asserted that he had reviewed the Veteran's claims file and that there was no change in his opinion regarding the Veteran's GERD. The foregoing statement is entirely unresponsive to the questions posed in the September 2012 Board remand. As such, another remand for corrective action is required. 38 C.F.R. § 4.2. See also Stegall, supra (noting that the Board errs as a matter of law when it fails to ensure compliance with a remand directive). The RO/AMC must schedule a VA digestive disorders examination for an opinion regarding the etiology of the Veteran's GERD or any other digestive disorder diagnosed. The examination instructions are contained in the first paragraph below. The Board, however, emphasizes that the content of the September 2012 remand is incorporated herein by reference. In short, the examiner must first diagnose all extant digestive disorders and determine whether any such disorder preexisted either the first or second period of the Veteran's active duty. If so, the examiner must opine regarding whether there also is clear and unmistakable evidence this pre-existing condition was not aggravated beyond its natural progression during or by the relevant period of active military service. If not, the examiner must opine regarding the likelihood (very likely, as likely as not, or unlikely) that any such disability is related to service. Accordingly, this remaining claim is REMANDED for the following additional development and consideration: 1. Schedule another VA digestive disorders examination for an additional opinion addressing the etiology of the Veteran's digestive disorder, diagnosed as GERD. The contents of the Board's prior September 2012 remand are incorporated herein by reference. In any event, the examiner must review all of the pertinent records in the claims file in addition to obtaining a thorough medical history from the Veteran. The following questions must be answered: (a) Considering the Veteran's January 1990 report of a history of frequent indigestion, did he clearly and unmistakably have a digestive disorder prior to beginning his first period of active service from September 1990 to June 1991? (b) If he did, is there also clear and unmistakable evidence this pre-existing condition was not aggravated beyond its natural progression during or by his first period of active military service from September 1990 to June 1991, including considering his April 1991 report of a history of frequent indigestion? (c) Else, considering the Veteran's April 1994 report of a history of frequent indigestion, did he clearly and unmistakably have a digestive disorder prior to beginning his second period of active service from January 2003 to July 2004? (d) If he did, is there also clear and unmistakable evidence this pre-existing condition was not aggravated beyond its natural progression during or by his second period of active military service from January 2003 to July 2004, including considering his May 2003 complaints of stomach pain and resultant diagnosis of dyspepsia, as well as his June 2004 report of a history of frequent indigestion? (e) If there is not this required clear and unmistakable evidence to satisfy this two-prong analysis, i.e., to establish the preexistence of the digestive disorder and that it was not aggravated during or by the Veteran's service beyond its natural progression, then also consider his reports of a history of frequent indigestion in April 1991, April 1994, June 2004, and November 2005, as well as his May 2003 complaints of stomach pain and resultant diagnosis of dyspepsia, in determining the likelihood (very likely, as likely as not, or unlikely) that any current digestive disorder, not just the GERD but also hiatal hernia, is related to or dates back to a period of active service, either the initial period from September 1990 to June 1991 or the later period from January 2003 to July 2004? It is essential in providing responses to these questions that the designated examiner adhere to the differing standards of proof. "Clear and unmistakable evidence" is a more formidable evidentiary burden of proof than the preponderance of the evidence standard. See Vanerson v. West, 12 Vet. App. 254, 258 (1999) (noting that the "clear and convincing" burden of proof, while a higher standard than a preponderance of the evidence, is a lower burden to satisfy than that of "clear and unmistakable evidence."). It is an "onerous" evidentiary standard, requiring that the preexistence of a condition and the non-aggravation result be "undebatable." Cotant v. Principi, 17 Vet. App. 116, 131 (2003), citing Laposky v. Brown, 4 Vet. App. 331, 334 (1993). "Very likely" obviously is supportive of the claim. The term "as likely as not" means at least 50-percent probability and is equally favorable to the claim. It does not however mean merely within the realm of medical possibility, rather, that the weight of evidence for and against a conclusion is so evenly divided that it is as reasonable to find in favor of causation as it is to find against it. "Unlikely" obviously tends to go against the claim. 2. Ensure this additional medical comment is responsive to the specific questions asked. If not, take corrective action. 38 C.F.R. § 4.2. See also Stegall v. West, 11 Vet. App. 268, 271 (1998). 3. Then readjudicate this remaining claim in light of this and all other additional evidence. If this claim continues to be denied, send the Veteran a supplemental statement of the case (SSOC) and give him an opportunity to submit additional evidence and/or argument in response before returning the file to the Board for further appellate consideration of this claim. He has the right to submit additional evidence and argument concerning this claim the Board is remanding. 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 or by the Court 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). ______________________________________________ KEITH W. ALLEN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs