Citation Nr: 1330383 Decision Date: 09/23/13 Archive Date: 09/30/13 DOCKET NO. 10-07 674 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to service connection for peripheral neuropathy of the right and left upper extremities, to include as secondary to type II diabetes mellitus. 2. Entitlement to service connection for hypertension, to include as secondary to type II diabetes mellitus. 3. Entitlement to service connection for a bladder condition. 4. Entitlement to service connection for acid reflux. 5. Entitlement to service connection for infection of the right and left hands. 6. Entitlement to service connection for a psychiatric disability, to include posttraumatic stress disorder (PTSD). 7. Entitlement to service connection for erectile dysfunction, to include as secondary to type II diabetes mellitus. 8. Entitlement to a total disability rating for individual unemployablity due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Andrew Mack, Counsel INTRODUCTION The Veteran served on active duty from November 1965 to November 1967. These matters come before the Board of Veterans' Appeals (Board) on appeal from an April 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. Regarding the Veteran's claim for an acquired psychiatric disorder, while the Veteran has claimed entitlement to service connection for PTSD, given the Veteran's description of his claim, the Board finds that the claim encompasses any acquired psychiatric disorder. See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (holding that the scope of a Veteran's claim for service connection for PTSD may also include any mental disability that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record). Therefore, the Board has characterized that portion of the appeal involving service connection for a psychiatric disability as encompassing any acquired psychiatric disorder, to include PTSD, as reflected on the title page. Also, during the pendency of his appeal, the Veteran raised the issue of entitlement to a TDIU. While the RO denied the claim in a September 2012 decision letter, when a request for a TDIU is made during the pendency of a claim, whether expressly raised by a veteran or reasonably raised by the record, it is not a separate claim for benefits, but rather involves an attempt to obtain an appropriate rating for a disability as part of the initial adjudication of the claim. Rice v. Shinseki, 22 Vet. App. 447, 453-454 (2009). Thus, the issue of entitlement to a TDIU is before the Board. The Board has not only reviewed the Veteran's physical claims file but also the Veteran's file on the "Virtual VA" system to ensure a total review of the evidence. The issues of entitlement to service connection for hypertension, to include as secondary to type II diabetes mellitus, and a TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran did not have peripheral neuropathy of the upper extremities at the time of his February 2009 claim for benefits and has not had any such disability at any time since. 2. The Veteran does not have any bladder condition that might be related to service. 3. No current acid reflux disability is related to service. 4. No disability involving infection of either hand is related to service in any way. 5. The Veteran did not have a psychiatric disability, to include PTSD, at the time of his February 2009 claim for benefits and has not had any such disability at any time since. 6. Erectile dysfunction was permanently aggravated by the Veteran's service-connected type II diabetes. CONCLUSIONS OF LAW 1. The criteria for service connection for peripheral neuropathy of the right and left upper extremities, to include as secondary to type II diabetes mellitus, have not been met. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309(a), 3.310 (2012). 2. The criteria for service connection for a bladder condition have not been met. 38 U.S.C.A. §§ 1110, 5107, 1154(b) (West 2002); 38 C.F.R. § 3.303 (2012). 3. The criteria for service connection for acid reflux have not been met. 38 U.S.C.A. §§ 1110, 5107, 1154(b) (West 2002); 38 C.F.R. § 3.303 (2012). 4. The criteria for service connection for infection of the right and left hands have not been met. 38 U.S.C.A. §§ 1110, 5107, 1154(b) (West 2002); 38 C.F.R. § 3.303 (2012). 5. The criteria for service connection for a psychiatric disability, to include PTSD, have not been met. 38 U.S.C.A. §§ 1110, 5107, 1154(b) (West 2002); 38 C.F.R. §§ 3.303, 4.125 (2012). 6. The criteria for service connection for erectile dysfunction have been met. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS 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; 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). 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. Service connection may also be granted for any disease diagnosed after discharge when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In addition, for certain chronic diseases, such as organic diseases of the nervous system, a presumption of service connection arises if the disease is manifested to a degree of 10 percent within one year of discharge from service. 38 C.F.R. §§ 3.307, 3.309(a). When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support a claim for such diseases. 38 C.F.R. §§ 3.303(b); see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be established on a secondary basis for a disability that is shown to be proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. Id.; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc) (additional disability resulting from aggravation of a nonservice-connected disorder by a service-connected disorder is also compensable under 38 C.F.R. § 3.310). With disability compensation claims, VA adjudicators are directed to assess both medical and lay evidence. As a general matter, a layperson is not capable of opining on matters requiring medical knowledge. See 38 C.F.R. § 3.159(a)(2); see also Routen v. Brown, 10 Vet. App. 183, 186 (1997). In certain circumstances, however, 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, 10 Vet. App. 183. 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. See generally 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. 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). In this case, the Veteran's service personnel records reflect that he earned the Combat Infantryman Badge, and he is therefore presumed to have engaged in combat. The events of the Veteran's service are not in dispute. In the case of any veteran who engaged in combat with the enemy in active service with a military, naval, or air organization of the United States during a period of war, campaign, or expedition, the Secretary shall accept as sufficient proof of service-connection of any disease or injury alleged to have been incurred in or aggravated by such service satisfactory lay or other evidence of service incurrence or aggravation of such injury or disease, if consistent with the circumstances, conditions, or hardships of such service, notwithstanding the fact that there is no official record of such incurrence or aggravation in such service, and, to that end, shall resolve every reasonable doubt in favor of the veteran. Service-connection of such injury or disease may be rebutted by clear and convincing evidence to the contrary. 38 U.S.C.A. § 1154(b). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. Peripheral neuropathy of the right and left upper extremities, to include as secondary to type II diabetes mellitus Initially, the record, including service and post-service treatment records, does not reflect, and the Veteran does not contend, that any peripheral neuropathy began in service or within a year of service. Thus, the presumptive service connection provisions of 38 C.F.R. § 3.307 and 3.309(a) are not applicable here. As reflected in a February 2010 statement, the Veteran contends that he has peripheral neuropathy of the upper extremities secondary to his service-connected type II diabetes mellitus. However, the Veteran's service connection claim must be denied. The only competent and probative evidence of whether the Veteran has peripheral neuropathy of either upper extremity are the reports of December 2009 and July 2012 VA examinations, both of which revealed that the Veteran does not have any peripheral neuropathy of the upper extremities, providing highly probative evidence against this claim. On December 2009 examination, the Veteran's strength was full in his upper extremities, grip was strong and normal bilaterally, and sensation was intact to light touch and vibration, and intact on the flexor aspect bilaterally to 10 gram monofilament; the examiner concluded that while there was evidence of peripheral neuropathy of the feet, there were no signs of peripheral neuropathy in the hands. On July 2012 VA examination, it was noted that there was no pain, paresthesias, dysthesias, or numbness of either upper extremity, that strength was full in the elbow, wrist, grip, and pinch, and that upper extremity reflexes were normal. Light touch and monofilament testing showed normal sensation in the shoulder area, inner and outer forearms, hands, and fingers. The examiner stated that the Veteran did not have an upper extremity peripheral neuropathy. The Board notes the Veteran's representative's assertion in a July 2013 brief that, as an electromyography (EMG) test was not performed on VA examination in assessing the existence of upper extremity peripheral neuropathy, "[t]he issue of bilateral peripheral neuropathy should be remanded in order for the [Veteran] to be provided an EMG test to determine whether his symptoms noted on VA examination of numbness and tingling can be verified via an EMG study." Initially, no symptoms of numbness or tingling were noted on VA examination; rather, such symptomatology was specifically noted not to have been present. Furthermore, both the December 2009 and July 2012 VA examiners, both medical professionals, found sufficient evidence on objective examination, which included light touch, pinprick, and monofilament examination, as well as strength and reflex testing, to determine that the Veteran did not have peripheral neuropathy of the bilateral upper extremities. In this regard, there is no competent and probative evidence of peripheral neuropathy, and neither the Veteran nor his representative has identified any, nor any competent medical evidence suggesting that either the December 2009 or July 2012 VA examinations were inadequate in any way to determine the presence of peripheral neuropathy. Also, the Veteran is competent to report matters within his own personal knowledge, such as any pain or numbness in his upper extremities. See Layno, 6 Vet. App. at 469. Lay evidence may be competent with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See Barr, 21 Vet. App. at 308-09 (concerning varicose veins). However, in this case the Veteran has made only vague assertions of peripheral neuropathy of the bilateral upper extremities, and complained in February 2010 that the December 2009 VA examiner did not test his hands or hand strength. Moreover, to the extent that the Veteran may be considered to have described any subjective symptomatology, a diagnosis of peripheral neuropathy is a determination medical in nature, and therefore requires medical expertise to make. As the weight of the evidence reflects that the Veteran did not have peripheral neuropathy of the upper extremities at the time of his February 2009 claim for benefits and has not at any time since, there can be no valid service connection claim for that disability. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); McClain v. Nicholson, 21 Vet. App. 319 (2007); Romanowsky v. Shinseki, No. 11-3272, 2013 WL 3455655 (Vet. App. July 10, 2013). Accordingly, the claim for service connection for peripheral neuropathy of the right and left upper extremities, to include as secondary to type II diabetes mellitus, must be denied. The Veteran's statements are simply outweighed by the medical evidence cited above on this medical issue. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 53-56. A bladder condition As reflected in a February 2010 statement, the Veteran contends that he has a bladder condition, but that such bladder condition is not present at all times and comes and goes with the help of antibiotics. Neither private nor VA medical records reflect a diagnosis of any bladder disorder. In September 2009 the Veteran reported on VA treatment that his urine flow was well-controlled on finasteride, but this treatment was in connection with a diagnosis of benign prostatic hypertrophy. The Board recognizes the Veteran's February 2010 statement that he had received treatment for a bladder condition shortly after a December 2009 VA examination. However, even assuming that the Veteran does receive treatment for a current bladder disability, or that the Veteran's claim encompasses his benign prostatic hypertrophy, there is no indication in the record as to how either such condition might be related to service or to a service-connected disability, and the Veteran has not offered any. In this regard, he has not asserted that any bladder or prostate condition actually began in service, and, at the time of his September 1967 examination for separation from service, he denied frequent or painful urination and did not report any bladder problems, providing evidence against his own claim even if the Board assues he currently has this problem, which is very unclear from this record. Thus, the weight of the evidence demonstrates that the Veteran does not have any bladder condition that might be related to service. Accordingly, the claim for service connection for a bladder condition must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 53-56. Acid reflux As reflected in a February 2010 statement, the Veteran contends that he has acid reflux, that he did not take any medication at the time but that he had in the past, that he had a restricted diet, and that there "should be something" in his medical records from the 1960s "about problems with [his] stomach." It is important for the Veteran to understand that even if this were true, it would not provide a basis to find a current problem in 2013. The evidence of record weighs against a finding that any current acid reflux disability is related to service. The record does not contain any current diagnosis of an acid reflux disorder, and no such disorder or related problems have been noted on examination. On December 2009 VA examination, the Veteran denied chronic nausea, vomiting, constipation, or diarrhea, providing factual evidence against his own claim. Service treatment records reflect treatment for intermittent stomach cramps, nausea, chills and diarrhea from December 30, 1966, to January 4, 1967, but no further treatment for stomach problems, and no treatment related to acid reflux. At the time of his September 1967 separation examination, the Veteran was noted to have had a normal evaluation of the mouth, throat, and abdomen, and no acid reflux condition was noted; at the time, the Veteran denied any history of frequent indigestion or stomach problems, and reported no acid reflux. However, even considering the Veteran's treatment for stomach problems in service, and assuming that he has current acid reflux, for which he has taken medication for in the past and for which he has a restricted diet, there is no competent evidence suggesting that any current problem might be related to service, or any other such indication of a nexus between any current acid reflux condition and service. The Veteran is competent to report matters within his own personal knowledge, such as having acid reflux or stomach problems in service, and having current stomach or digestion pain or problems that began in service. See Layno, 6 Vet. App. at 469. However, to the extent that the Veteran asserts any such continuity of symptomatology, given the total lack of any medical records relating to this condition, the length of time between the Veteran's discharge from service in November 1967 and his February 2009 claim, and the Veteran's own statements at the time of his separation examination, which contradict any such assertion, the Board finds that such assertion is not credible. Accordingly, the Board finds that the claim for service connection for acid reflux must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 53-56. Infection of the right and left hands As reflected in a February 2010 statement, the Veteran contends that he receives current treatment for his hands, and that there "should be something" in his medical records from 1967 "about the infection on [his] feet and around [his] groin." However, as above, this service connection claim must be denied. In short, the record does not reflect any disability involving infection of either hand that might be related to service in any way. Service treatment records reflect treatment for lesions, warts, and rashes in the groin and genital area, primarily related to venereal disease. However, the September 1967 report of examination for separation from service reflects a normal clinical evaluation of the upper extremities, and the Veteran denied any history of skin diseases and reported no history of problems with his hands, providing more factul evidence against his own claim. The medical evidence does not show that the Veteran had, at the time of his February 2009 claim for service connection, or has had since, any infections of the hands. Private treatment records reflect treatment in June 2000 for right hand pain with weak grip and swelling, with the Veteran reported having had for five days, and that in December 2002 the Veteran was treated for a right forearm infection. However, there is no indication of any current disability involving infection of the hands, or how any such disability might be related to service in any way. The medical evidence as a whole simply does not reveal a chronic disability at this time. The Veteran is competent to report matters within his own personal knowledge. See Layno, 6 Vet. App. at 469. However, the Veteran has not stated that he has had recurrent infections of the hands from the time of service; rather he has asserted that he was treated for infection of the feet and groin in 1967. The Veteran has not stated what the nature or symptoms of any current infection of the hands might be or how such any such infection might be related to service, including any in-service groin or foot infection, or identified any competent evidence explaining such. In light of the above, the Board finds that the evidence weighs against any finding that infection of the right or left hand is in any way related to service. Accordingly, the Board finds that the claim for service connection for infection of the right and left hands must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 53-56. A psychiatric disability, to include PTSD To establish entitlement to service connection for PTSD the evidence must satisfy three basic elements. There must be 1) medical evidence diagnosing PTSD; 2) a link, established by medical evidence, between current symptoms of PTSD and an in-service stressor; and 3) credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f). The first requirement for service connection for PTSD is a medical diagnosis of the condition. Diagnoses of PTSD must be rendered in accordance with the diagnostic criteria for the condition set forth in the Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). See 38 C.F.R. § 4.125 (noting that VA has adopted the nomenclature of the DSM-IV). If the evidence establishes that a veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran's service, his testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304(f)(1). See also 38 U.S.C.A. § 1154(b). As reflected in a February 2010 statement, the Veteran contends that he had a lot of stressors as a point man for five months and a driver of an armored personnel carrier (APC) for seven months, which is fully conceded. However, the Veteran's service connection claim for a psychiatric disability, to include PTSD, must be denied. In short, the weight of the evidence demonstrates that the Veteran does not have a psychiatric disability, including PTSD. The only medical evidence of record relating to PTSD or any other psychiatric disability is the report of a December 2009 VA examination. At the time of the examination, the Veteran was noted to have served in Vietnam as a combat infantryman for one year. The Veteran reported having no difficulty sleeping unless he took a nap late in the day, and having an occasional nightmare and flashback, which had reportedly lessened over time. He also reported still having an exaggerated startle response, but that this did not cause undue distress, that he remained hypervigilant toward danger but saw this as necessary for living where he lived, and that he had no difficulty in crowds or being around other people. There was no history of suicidal or homicidal ideation, plan, or attempt endorsed. It was noted that he was placed at a computer to complete the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) and PTSD Checklist Military (PCLM) for assessment of PTSD symptoms, but did not complete either of these, and that there was no psychometric measure to help with a diagnosis. The examiner stated that the Veteran met Criterion A for PTSD by virtue of an experience in which the APC he was driving hit a landmine, but that he did not, however, appear to meet Criterion B, as he slept well with only occasional nightmares and flashbacks that occurred after watching war movies, and that he did not meet Criterion C in that he did not actively avoid talking or thinking about his experiences in Vietnam. Thus, according to the examiner, the Veteran failed to meet the minimum requirements for a diagnosis of PTSD, providing highly probative evidence against a finding that the Veteran has PTSD at this time. The examiner concluded that the Veteran was currently not considered to be impaired in the least due to his experiences in Vietnam and did not meet the criteria for a diagnosis of PTSD, even thought there was an event that occurred during his tour in Vietnam that could have produced such trauma. The assessment was no Axis I diagnosis, with Global Assessment of Functioning (GAF) score currently 90. In this case, any claimed stressor of the Veteran consistent with the circumstances, conditions, or hardships of his combat service is conceded, including that the APC that he was driving in service hit a landmine. In fact, service treatment records confirm that the Veteran was treated for a contusion of the lower lip after the APC that he was in was stuck by a mine. The stressors of the Veteran's highly honorable service is simply not the issue. However, even given any such conceded stressors, the competent and probative evidence does not show any current psychiatric disability, including PTSD. Again, the December 2009 VA examination is the only medical evidence addressing any psychiatric disability, including PTSD. The Board notes the Veteran's representative's contention in a July 2013 brief that "[t]he examiner who conducted the VA examination dated December 3, 2009, notes that the [Veteran] was placed at a computer to complete the MMPI-2 and the PCLM for assessment of PTSD symptoms but did not complete either of the tests," and therefore that "[t]he [Veteran] should be rescheduled for a VA psychiatric examination so that he may be given the opportunity to complete the MMPI and PCLM assessment that he could [not] complete during the VA examination." However, despite the lack of psychometric examination findings, which was the result of the Veteran not completing the tests, rather than any lack of attempt to test by the examiner, the Board nonetheless finds the examination report to be highly probative. It was completed by a mental health professional with appropriate expertise who reviewed the claims file, interviewed the Veteran and obtained an accurate history of his service and in-service stressful event, which the examiner conceded could have been the basis for any current PTSD, and performed a thorough mental health examination, despite the lack of any psychometric test results. Based on the information contained in the claims file and obtained during the examination, the examiner was able to determine that the Veteran did not meet the criteria for a diagnosis of PTSD and did not have a diagnosed psychiatric disorder, and that the Veteran "currently is not considered to be impaired in the least due to his experiences in Vietnam." Moreover, and perhaps more importantly, there is no other medical evidence suggesting that the Veteran has a psychiatric disability or otherwise contradicting the findings of the December 2009 VA examiner or indicating why the December 2009 VA examination might have been inadequate to determine whether the Veteran has PTSD or another psychiatric disorder, and neither the Veteran nor his representative has identified any. The only evidence the Board has of a mental disorder indicates that the Veteran does not have PTSD, which only provides evidence against this claim. As the weight of the evidence reflects that the Veteran did not have a psychiatric disability, to include PTSD, at the time of his February 2009 claim for benefits or has had such disability at any time since, there can be no valid service connection claim for any such disability. See Gilpin, 155 F.3d 1353; Brammer, 3 Vet. App. at 225; McClain, 21 Vet. App. 319; Romanowsky, No. 11-3272, 2013 WL 3455655. Accordingly, the claim for service connection for a psychiatric disability, to include PTSD, must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 53-56. Erectile dysfunction, to include as secondary to type II diabetes mellitus Finally, the Veteran's service connection claim for erectile dysfunction must be granted. In the report of a December 2009 VA examination, and again in a July 2011 addendum, a VA physician diagnosed erectile dysfunction and opined that, while erectile dysfunction predated the Veteran's service-connected type II diabetes, it was at least as likely as not that a worsening in erectile dysfunction after the onset of diabetes was secondary to such diabetes. There is no competent evidence contradicting the examiner's opinion. Accordingly, resolving any reasonable doubt in favor of the Veteran, the claim for service connection for erectile dysfunction must be granted. Id. Duties to Notify and Assist Under applicable criteria, VA has certain notice and assistance obligations to claimants. See 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). Notice must be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim for VA benefits and must: (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II). With respect to service connection claims, section 5103(a) notice should also advise a claimant of the criteria for establishing a disability rating and effective date of award. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 486 (2006). In the present case, required notice was provided by letter dated in February 2009, which informed the Veteran of all the elements required by Pelegrini II and Dingess/Hartman. While February 2009 notice letter did not notify the Veteran of the criteria for substantiating a service connection claim on a secondary basis, notice of such criteria were provided to the Veteran in the December 2009 statement of the case, and, subsequently, in a June 2012 notice letter. An October 2012 supplemental statement of the case reflects the most recent readjudication of the Veteran's claims. Hence, the Veteran is not shown to be prejudiced by any initial error in notice. As to VA's duty to assist, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). This duty includes assisting the Veteran in the procurement of service medical records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In determining whether the duty to assist requires that a VA medical examination be provided or medical opinion obtained with respect to a Veteran's claim for benefits, there are four factors for consideration. These four factors are: (1) whether there is competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) whether there is evidence establishing that an event, injury, or disease occurred in service, or evidence establishing certain diseases manifesting during an applicable presumption period; (3) whether there is an indication that the disability or symptoms may be associated with the Veteran's service or with another service-connected disability; and (4) whether there otherwise is sufficient competent medical evidence of record to make a decision on the claim. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4). With respect to the third factor above, the Court of Appeals for Veterans Claims has stated that this element establishes a low threshold and requires only that the evidence "indicates" that there "may" be a nexus between the current disability or symptoms and the Veteran's service. The types of evidence that "indicate" that a current disability "may be associated" with military service include, but are not limited to, medical evidence that suggests a nexus but is too equivocal or lacking in specificity to support a decision on the merits, or credible evidence of continuity of symptomatology such as pain or other symptoms capable of lay observation. McLendon v. Nicholson, 20 Vet. App. 79 (2006). In this case, a VA examination was not obtained specifically for the service connection claims for a bladder condition, acid reflux, and right and left hand infection because the evidence did not surpass the low threshold set by McLendon. Where the evidence does not establish that a disability may be associated with service, there is no need to obtain a medical opinion regarding any such nexus. As discussed above, there is no medical or other competent evidence suggesting that a bladder condition, acid reflux, or right and left hand infection might be related to service in any way or any other such evidence that would warrant obtaining a medical nexus opinion. The Veteran's own statements, overall, support this finding, at this time. In this regard, the Federal Circuit has addressed the appropriate standard to be applied in determining whether an examination is warranted. In Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010) and Colantonio v. Shinseki, 606 F.3d 1378 (Fed. Cir. 2010), the Federal Circuit held that while there must be "medically competent" evidence of a current disability, "medically competent" evidence is not required to indicate that the current disability may be associated with service. Colantonio, 606 F.3d at 1382; Waters, 601 F.3d at 1277. On the other hand, a conclusory generalized lay statement suggesting a nexus between a current disability and service (as in the case of these claims, a best, with some instances of the Veteran himself failing to indicate that these problems currently exist) would not suffice to meet the standards, as this would, contrary to the intent of Congress, result in medical examinations being "routinely and virtually automatically" provided to all veterans claiming service connection. Waters, 601 F.3d at 1278-1279. Here, as the only evidence that the Veteran's claimed disabilities are related to military service is the conclusory generalized lay statements of the Veteran, which are unsupported by even speculative medical evidence. Accordingly, the Board finds that referral for a VA medical examination is not warranted. The Veteran's service treatment records, VA medical treatment records, and identified private treatment records have been obtained. Also, the Veteran was provided VA examinations regarding his claimed peripheral neuropathy and psychiatric disability in December 2009 and July 2012. These examinations and their associated reports were adequate because, along with the other evidence of record, they provided sufficient information to decide the appeal and a sound basis for a decision on the Veteran's claims. The examination reports were based on examination of the Veteran by examiners with appropriate expertise who reviewed the claims file. 38 C.F.R. § 3.159(c)(4) (2012); Barr, 21 Vet. App. 303. Regarding the peripheral neuropathy examinations, the Board notes the Veteran's representative's contentions in a July 2013 brief that, as EMG testing was not performed on VA examination in assessing the existence of upper extremity peripheral neuropathy, "[t]he issue of bilateral peripheral neuropathy should be remanded in order for the [Veteran] to be provided an EMG test to determine whether his symptoms noted on VA examination of numbness and tingling can be verified via an EMG study." However, as noted above, no symptoms of numbness or tingling were noted on VA examination; rather, such symptomatology was specifically noted not to have been present. Furthermore, both the December 2009 and July 2012 VA examiners, both medical professionals, found sufficient evidence on objective examination, which included light touch, pinprick, and monofilament examination, as well as strength and reflex testing, to determine that the Veteran did not have peripheral neuropathy of the bilateral upper extremities, and there is no competent medical evidence suggesting that either the December 2009 or the July 2012 VA examinations were inadequate in any way to determine the presence of peripheral neuropathy. Also, the Board acknowledges the Veteran's assertion in February 2010 that the December 2009 VA examiner did not examine the Veteran's hands or test hand strength. However, the findings of the December 2009 VA examiner clearly reflect examination, including muscle, grip strength, and sensory, of the hands. Moreover, such function of the hand was again tested during the July 2012 test. Thus, the Board finds the December 2009 and July 2012 VA examinations adequate as medical evidence to decide his peripheral neuropathy claim, and remand for another examination is not warranted. The Board also notes the Veteran's representative's contention in the the July 2013 brief, that "[t]he examiner who conducted the VA examination dated December 3, 2009, notes that the [Veteran] was placed at a computer to complete the MMPI-2 and the PCLM for assessment of PTSD symptoms but did not complete either of the tests," and therefore that "[t]he [Veteran] should be rescheduled for a VA psychiatric examination so that he may be given the opportunity to complete the MMPI and PCLM assessment that he could [not] complete during the VA examination." However, for the reasons discussed above, despite the lack of psychometric examination findings, the Board nonetheless finds the examination report to be highly probative. Moreover, such lack of psychometric test findings was the result of the Veteran not completing the tests, rather than any lack of attempt to test by the examiner. The Board observes that "the duty to assist is not always a one-way street." Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). Therefore, the Board finds that VA has fulfilled any duty to provide an adequate examination of the Veteran's claimed psychiatric disability in this case, and remand for further examination is not warranted. Finally, the Board acknowledges the Veteran's assertions in a February 2010 statement that, despite the fact that his bladder condition was not present at the time of his December 2009 VA examination, he was treated for it about three weeks later; it does not appear that such subsequent treatment records are contained in the claims file. However, as explained above, even assuming that the Veteran does receive treatment for a current bladder disability (the Board assumes that the Veteran's treatment did occur), there is no indication in the record as to how such condition might be related to service or to a service-connected disability, and the Veteran has not offered any; he has not asserted that any bladder condition actually began in service, and at the time of his September 1967 examination for separation from service he denied frequent or painful urination and did not report any bladder problems. Thus, the Board finds that the Veteran is not prejudiced by the absence of any such records indicating treatment for a bladder condition in this case, and that it may proceed with a final decision on the matter. Therefore, VA has satisfied its duties to notify and assist, and additional development efforts would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). Because VA's duties to notify and assist have been met, there is no prejudice to the Veteran in adjudicating this appeal. ORDER Service connection for peripheral neuropathy of the right and left upper extremities, to include as secondary to type II diabetes mellitus, is denied. Service connection for a bladder condition is denied. Service connection for acid reflux is denied. Service connection for infection of the right and left hands is denied. Service connection for a psychiatric disability, to include PTSD, is denied. Service connection for erectile dysfunction is granted. REMAND While in the report of a December 2009 examination a VA physician stated that the Veteran's hypertension was diagnosed years before his service-connected type II diabetes was, neither the VA physician, nor any other examiner, has made any comment as to whether such diabetes has aggravated the Veteran's hypertension. In this regard, in a February 2010 statement, the Veteran asserted that his hypertension medication was significantly increased after the onset of his diabetes. Thus, the Veteran has not been afforded an adequate opinion regarding the etiology of his hypertension. As the Veteran's TDIU claim is inextricably intertwined with the claim for hypertension, it must also be remanded. See Henderson v. West, 12 Vet. App. 11, 20 (1998); Harris v. Derwinski, 1 Vet. App. 180, 183 (1991); see also 38 C.F.R. § 4.16(a). Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a VA examination with an appropriate examiner to determine the etiology of any hypertension. The claims file and a copy of this Remand must be made available to and reviewed by the examiner in conjunction with the examination. All pertinent symptomatology and findings must be reported in detail. The examiner must record all pertinent medical complaints, symptoms, and clinical findings, and must review the results of any testing prior to completion of the report. Following a review of the claims file, the examiner is requested to determine whether it is at least as likely as not (i.e. a 50 percent probability or more) that hypertension is aggravated (permanently worsened beyond its natural progression) by the Veteran's service-connected type II diabetes mellitus. A complete rationale for all opinions must be provided. 2. After completing the above development, and any other development deemed necessary, readjudicate the issues remaining on appeal. If any benefit sought remains denied, provide an additional supplemental statement of the case to the Veteran and his representative, and return the appeal to the Board for appellate review, after the Veteran has had an adequate opportunity to respond. The Veteran 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). ______________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs