Citation Nr: 1331991 Decision Date: 10/03/13 Archive Date: 10/07/13 DOCKET NO. 06-17 258 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for pectus excavatum (a bony deformity of the sternum or breast bone). 2. Entitlement to service connection for heart disease, to include coronary artery disease (CAD), myocardial infarction (MI), and atrial fibrillation, to include as due to pectus excavatum. 3. Entitlement to service connection for a seizure disorder. REPRESENTATION Veteran represented by: Virginia A. Girard-Brady, Attorney-at-Law ATTORNEY FOR THE BOARD M.W. Kreindler, Counsel INTRODUCTION The Veteran had active military service from April 1971 to March 1973. This matter came before the Board of Veterans' Appeals (Board) on appeal of January 2006 and August 2006 rating actions by the Department of Veterans Affairs (VA) Regional Office (RO) located in Waco, Texas. In the January 2006 rating action, the RO denied the Veteran's claims of entitlement to service connection for pectus excavatum and a seizure disorder. In February 2006, the Veteran filed a Notice of Disagreement (NOD) in which he only addressed his claim of service connection for pectus excavatum. A Statement of the Case (SOC) was issued in May 2006 and the Veteran submitted a substantive appeal (VA Form 9) later that month. In a deferred rating action, dated in May 2006, the RO noted that based upon statements from the Veteran and private medical statements submitted on the Veteran's behalf, it appeared that he was raising the issue of entitlement to service connection for MI, to include as secondary to his (nonservice-connected) pectus excavatum. The aforementioned issue was subsequently denied by the RO in an August 2006 rating action. In September 2006, the Veteran submitted an NOD in which he expressed disagreement with the RO's decision to deny service connection for MI. He also expressed disagreement with the RO's decision to deny service connection for a seizure disorder. An SOC was issued in November 2006, and the Veteran submitted a timely substantive appeal in December 2006. By a July 2009 decision, the Board denied the Veteran's claims. The Veteran, thereafter, appealed the July 2009 Board decision to the United States Court of Appeals for Veterans' Claims (Court). In May 2011, the Court issued a Memorandum Decision wherein it vacated the Board's July 2009 decision and remanded the case for action consistent with its decision. A copy of the Court's Memorandum Decision has been placed in the claims file. These matters were remanded in January 2012 for further development. In June 2013, the Board sought a VHA expert opinion as to the Veteran's seizure claim. Such opinion was provided in August 2013. FINDINGS OF FACT 1. Pectus excavatum is a congenital defect, which was diagnosed at the Veteran's October 1970 pre-induction examination; there is no evidence of a superimposed disease or injury during service that created additional disability. 2. The preponderance of the evidence is against a causal link between the Veteran's heart disease, to include CAD, MI, and atrial fibrillation, and any incident of or finding recorded during service. 3. A seizure disorder is due to a head injury sustained in service. CONCLUSIONS OF LAW 1. The criteria for an award of service connection for pectus excavatum have not been met. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2013); VAOPGCPREC 82-90. 2. The criteria for an award of service connection for heart disease, to include CAD, MI, and atrial fibrillation, have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2013). 3. The criteria for an award of service connection for a seizure disorder have been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In addition, the notice requirements of the VCAA apply to all elements of a service-connection claim, including the degree of disability and the effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. VCAA notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). In light of the favorable decision as it relates to the issue of the grant of service connection for a seizure disorder, no further discussion of VCAA is necessary. With regard to the remaining issues, the Veteran was sent letters in November 2005, March 2006, and June 2006 that provided information as to what evidence was required to substantiate the claims and of the division of responsibilities between VA and a claimant in developing an appeal. The March 2006 letter explained what type of information and evidence was needed to establish a disability rating and effective date. Although complete notice as to the pectus excavatum claim did not pre-date the adverse decision on appeal, corrective notice was followed by readjudication, curing the timimg defect. Accordingly, no further development is required with respect to the duty to notify. Next, VA has a duty to assist the Veteran in the development of the claims. This duty includes assisting him in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, to include substantial compliance with the January 2012 Board Remand. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). Therefore, appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The evidence of record contains the Veteran's service treatment records, and post-service treatment records. The Board otherwise concludes that no available outstanding evidence has been identified pertaining to the claims. The Board has also perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the claims. In June 2012, the Veteran underwent a VA examination pertaining to the claims on appeal, and in August 2012 an addendum opinion was proffered. The examination report and opinions will be discussed in detail below. McLendon v. Nicholson, 20 Vet. App. 79 (2006). For the above reasons, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist in the development of the claims. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Criteria & Analysis Service connection will be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110. 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). Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden/Caluza element is through a demonstration of continuity of symptomatology. Barr v. Nicholson, 21 Vet. App. 303 (2007); see Savage v. Gober, 10 Vet. App. 488, 495-97 (1997); see also Clyburn v. West, 12 Vet. App. 296, 302 (1999). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post- service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Savage, 10 Vet. App. at 495-96; see Hickson, 12 Vet. App. at 253 (lay evidence of in-service incurrence sufficient in some circumstances for purposes of establishing service connection); 38 C.F.R. § 3.303(b). However, an award of service connection based on continuity of symptomatology is only possible for claims based on chronic diseases as listed under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In adjudicating this claim, the Board must assess the Veteran's competence and credibility. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Washington v. Nicholson, 19 Vet. App. 362, 368- 69 (2005). In Barr v. Nicholson, 21 Vet. App. 303 (2007), the Court emphasized that lay testimony is competent if it pertains to matters that the witness has actually observed and is within the realm of the witnesses personal knowledge. See also 38 C.F.R. § 3.159(a)(2) (Competent lay evidence means any evidence not requiring that the proponent have specialized education, training or experience. Lay evidence is competent if it is provided by a person who has knowledge of the facts or circumstances and conveys matters that can be observed and described by a lay person). Certain chronic diseases, such as malignant tumors, are presumed to have been incurred in service if manifested to a compensable degree within one year of discharge from service; or if manifested in service and at any time thereafter. 38 U.S.C.A. § 1112; 38 C.F.R. §§ 3.303(b), 3.307, 3.309. Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). The provisions of 38 C.F.R. § 4.9, 4.57 make a distinction between congenital and acquired defects. Service connection for congenital or developmental defect is precluded by 38 C.F.R. § 3.303(c), 4.9. VA's Office of the General Counsel has distinguished between congenital or developmental defects, for which service connection is precluded by regulation, and congenital or hereditary disease, for which service connection may be grated, if initially manifested in or aggravated by service. O.G.C. Prec. Op. 82-90, 55 Fed Reg. 45711 (1990); O.G.C. Prec. Op. 67-90, 55 Fed. Reg. 43253 (1990). Defects were defined as "structural or inherent abnormalities or conditions that are more or less stationary in nature." O.G.C. Prec. Op. 82-90, 55 Fed. Reg. 45711 (1990). However, congenital or development defects may be service-connected where a superimposed injury occurs during, or as a result of, active service. VAOPGCPREC 82-90. Pectus excavatum and heart disease Service treatment records reflect that in October 1970, the Veteran underwent a pre-induction examination. At that time, his lungs and chest were clinically evaluated as "abnormal." The examiner determined that the Veteran had pectus excavatum (a bony abnormality of the chest or more specifically the breast bone-see analysis below), which was not considered disabling (NCD). The Veteran's heart was clinically evaluated as "normal." In June 1971, the Veteran was treated for complaints of chest pain. He stated that his pain was secondary to his pectus excavatum or deformity of the chest and was "getting worse." According to the Veteran, the pain was related to exertion. He was referred to the chest clinic where he had an x-ray taken of his chest. The x-ray was reported to show severe pectus excavatum with anomalous conjoined right 2nd and 3rd ribs. The examiner stated that the type of chest pain that the Veteran described was quite commonly seen in his condition, probably on a musculo-skeletal basis. There was no history of trauma to the chest. The physical examination showed that the Veteran had a significant pectus excavatum deformity. However, there was good chest expansion and the lungs were clear to percussion and auscultation. Cardiac examination revealed a bradycardia of 60 beats per minute. There were no precordial lifts, thrills, or heaves, although the second heart sound was palpable. The second heart sound was physiologically split and was accentuated, particularly the pulmonic component, which probably related to the close proximity of the chest wall to the great vessels. A faint Grade I/VI systolic murmur of ejection quality was noted over the left second intercostal space. No murmurs or gallops were appreciated. There was no peripheral edema, cyanosis or clubbing. The electrocardiogram was within normal limits. A diagnosis of heart disease, to include coronary artery disease and a myocardial infarction, was not recorded. In August 1971, the Veteran had complaints of chest pain, and in November 1972, he was assessed as having chest wall pain. In January 1973, the Veteran underwent an ETS (expiration of term of service) examination. At that time, in response to the question of whether he had ever had or if he currently had shortness of breath, he responded "yes." The Veteran's lungs and chest, and heart were clinically evaluated as "abnormal." It was noted that he had a history of pectus excavatum and a second heart sound. A diagnosis of heart disease, to include coronary artery disease and a myocardial infarction, was not recorded upon the separation examination or at any point during service. In October 2005, the Veteran filed a claim of entitlement to service connection for pectus excavatum or a deformity of the chest. In a February 2006 private medical statement, C.A.S., M.D., stated that the Veteran had been recently hospitalized with a large anterior myocardial infarction. Upon admission, he was found to have total occlusion of the left anterior descending coronary artery. Angioplasty and stent implantation were performed to re-open the infarct-related vessel. Dr. S. noted that the Veteran had coronary disease and left ventricular dysfunction. In a subsequent statement, dated in March 2006, Dr. S. reported that the Veteran had a complex coronary anatomy. Specifically, Dr. S. noted that the Veteran had what he would consider bifurcation disease involving the distal left main coronary artery, ostium of the left anterior descending coronary artery and ostium of the ramus branch. In addition, the left anterior descending had bifurcation disease which involved the origin of a good-sized diagonal branch. In December 2007, the RO received records from the Social Security Administration (SSA), which included a Disability Determination and Transmittal Report, dated in April 2006. The SSA report shows that the Veteran was awarded SSA disability benefits for essential hypertension (primary diagnosis); valvular heart disease or other stenotic defects or valvular regurgitation; and endocardititis (secondary diagnosis). The records included VA Medical Center (VAMC) outpatient treatment records, dated from April 2004 to December 2007. The records reflect that in April 2006, the Veteran was diagnosed with CAD, status post prophylactic cranial irradiation (PCI) with stent placement, left anterior descending, with left main distal stenosis. In June 2012, the Veteran underwent a VA examination. The examiner explained that the Veteran has pectus excavatum, which is a defect not a disease. Specifically, the examiner explained that it is a congenital defect in which the breast bone is sunken in. The examiner opined that there was no evidence that there was any superimposed disease or injury in connection with the pectus excavatum. In so finding, the examiner reasoned that the Veteran recalled no injury or treatment for disease associated with his chest deformity. The Veteran's complaints of chest pain may have been related to the pectus excavatum, but this was not related to any heart condition brought on by the deformity, but rather due to the deformity itself. The examiner explained that the "second heart sound" would indicate a murmur that would not be related to the pectus excavatum but more likely than not to either a heart valve or to a physiologic second heart sound not related to the chest wall deformity. The Veteran's CAD/MI is not due to or caused by the pectus excavatum. The examiner opined that his pectus excavatum was not aggravated by active service. The June 2012 VA examiner also opined that his CAD, MI, and atrial fibrillation are less likely than not due to service. The examiner explained that his CAD, MI, and atrial fibrillation are not related to his complaints of chest pain or second heart sound while in service. The examiner opined that his CAD/MI is more likely than not related to his tobacco abuse history as well as his elevated cholesterol and his hypertension. It is not related to his pectus excavatum which is a congenital defect that may have been responsible for pain in his chest but would not lead to CAD/MI or atrial fibrillation. It is unlikely that complaints of chest pain and second heart sounds in 1971-1973 would present as CAD/MI/atrial fibrillation in 2006, but would have presented much earlier. In addition, the Veteran has a family history of heart disease and stroke. In an August 2012 VA addendum opinion, the examiner noted review of the claims folders and reiterated that the Veteran's pectus excavatum is a congenital abnormality (defect) not a disease. The examiner stated that his pectus excavatum would not improve and there is not any superimposed disease or injury connected with it that was or could be related to his military service. The examiner opined that this condition was not aggravated by his military service. The examiner explained that this condition would have nothing to do with his "second heart sound" which is physiologically related to the functioning of his heart (but not related to his ischemic heart disease later in life). His pectus excavatum could cause some chest discomfort, but with any activity, not just activity related to his active military service (not aggravated by service beyond its natural progression). In regards to his chest pain in service as related to possible ischemic heart disease, the Veteran had a normal EKG in service treatment records, and notes by physicians that the chest pain was more likely than not related to pectus excavatum and not related to ischemic heart disease. Pectus excavatum Pectus excavatum is defined as "undue depression of the sternum; called also funnel breast or chest." See Dorland's Illustrated Medical Dictionary 1245 (27th ed. 1985). As explained below, the medical evidence shows that this bony abnormality is a congenital defect that was noted upon service entrance and that it was not subjected to a superimposed disease or injury during service that created additional disability. Upon the Veteran's pre-induction examination in October 1970, he was diagnosed with pectus excavatum deformity of the chest. Pectus excavatum is not a "disability" for VA compensation purposes. 38 C.F.R. §§ 3.303(c), 4.9. Congenital or developmental defects may not be service-connected because they are not diseases or injuries under the law. 38 C.F.R. §§ 3.303(c), 4.9; Beno v. Principi, 3 Vet. App. 439 (1992). VA regulations specifically prohibit service connection for a congenital defect unless it was subjected to a superimposed disease or injury which created additional disability. See VAOPGCPREC 82-90 (service connection may not be granted for defects of congenital, developmental or familial origin, unless the defect was subject to a superimposed disease or injury). A defect is a structural or inherent abnormality or condition, which is more or less stationary in nature. A disease may be defined as any deviation from or interruption of the normal structure or function of any part, organ, or system of the body that is manifested by a characteristic set of symptoms and signs and whose etiology, pathology, and prognosis may be known or unknown. See VAOPGCPREC 1-85 (March 5, 1985) (reissued as VAOPGCPREC 82- 90). There is no competent evidence which shows that the Veteran's pectus excavatum was subject to an in-service superimposed disease or injury that created additional disability. The Veteran's service treatment records reflect that in June 1971, when he was evaluated for chest pain related to his chest deformity, the examiner specifically stated that there was no history of trauma to the chest. The chest deformity was noted upon his pre-induction examination in October 1970, and again at the time of his ETS examination in January 1973. The service treatment records bear no indication of any other lung or chest malady apart from the diagnosed pectus excavatum and an isolated complaint of chest wall pain and there is no history of in-service chest trauma. Again, as explained by the June 2012 VA examiner, the Veteran's complaints of in-service chest pain may have been related to the pectus excavatum, but this was not related to any heart condition brought on by the deformity, but rather due to the deformity itself. The examiner explained that the "second heart sound" would indicate a murmur that would not be related to the pectus excavatum but more likely than not to either a heart valve or to a physiologic second heart sound not related to the chest wall deformity. The examiner opined that his pectus excavatum was not aggravated by active service. The opinion of the June 2012 VA examiner leads to a finding that the Veteran's pectus excavatum is a congenital defect and was not subject to a superimposed disease or injury. The Board accepts the examiner's opinion as being the most probative medical evidence on the subject, as such was based on a review of all historical records, and contains detailed rationale for the medical conclusions. See Boggs v. West, 11 Vet. App. 334 (1998). Given the depth of the examination report, and the fact that the opinion was based on a review of the applicable record, the Board finds such opinion is probative and material to the Veteran's claim. See Owens v. Brown, 7 Vet. App. 429 (1995). Moreover, there is no contrary opinion of record. Based on the foregoing, the Board finds that service connection for pectus excavatum is not warranted. 38 C.F.R. §§ 3.303(c), 4.9; VAOPGCPREC 82-90; see also Parker v. Derwinski, 1 Vet. App. 522 (1991). In reaching this decision, the Board considered the doctrine of reasonable doubt. However, since the preponderance of the evidence is against the claim, the benefit of the doubt doctrine does not apply. 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364, 1365 (Fed. Cir. 2001) (holding that "the benefit of the doubt rule is inapplicable when the preponderance of the evidence is found to be against the claimant"); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Heart disease Based on a thorough review of the record, the Board finds that the preponderance of the evidence is against the claim of service connection for heart disease, to include CAD, myocardial infarction, and atrial fibrillation. The Board recognizes that at the time of the January 1973 ETS examination, the Veteran's heart was clinically evaluated as "abnormal." However, this evaluation was in reference to the June 1971 finding of a second heart sound, not heart disease. There is also a reference to a heart murmur at that time. However, an electrocardiogram in June 1971 was within normal limits and the service treatment records, to include the separation examination, are negative for a diagnosis of any type of heart disease. In this case, the first medical evidence of record of heart disease, to include CAD and a MI, is seen in February 2006, approximately 33 years after the Veteran's separation from the military. With respect to negative evidence, the Court has held that the fact that there was no record of any complaint, let alone treatment, involving the veteran's condition for many years is a factor for consideration. See Maxson v. West, 12 Vet. App. 453, 459 (1999), affirmed sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000), [it was proper to consider the veteran's entire medical history, including a lengthy period of absence of complaints]; see also Forshey v. Principi, 284 F.3d 1335 (Fed. Cir. 2002) ["negative evidence" could be considered in weighing the evidence]. Moreover, as detailed above, the June 2012 VA examiner opined that the Veteran's CAD, MI and atrial fibrillation are not related to his in-service chest complaints nor to his second heart sound in service. Nor are these conditions due to his pectus excavatum, which is a congenital defect. As the examiner explained, while the Veteran may have experienced pain during service due to his pectus excavatum, this would not lead to CAD, MI or atrial fibrillation. The examiner explained that it is unlikely that complaints of chest pain and second heart sounds would present as CAD, MI, and atrial fibrillation in 2006, over 30 years after separation from service. The examiner opined that it would have presented much earlier. The opinion of the June 2012 VA examiner leads to a finding that the Veteran's CAD, MI, and atrial fibrillation are less likely than not related to service. Again, the Board accepts the examiner's opinion as being the most probative medical evidence on the subject, as such was based on a review of all historical records, and contains detailed rationale for the medical conclusions. See Boggs v. West, 11 Vet. App. 334 (1998). Given the depth of the examination report, and the fact that the opinion was based on a review of the applicable record, the Board finds such opinion is probative and material to the Veteran's claim. See Owens v. Brown, 7 Vet. App. 429 (1995). Moreover, there is no contrary opinion of record. As the examiner noted in the August 2012 addendum opinion, other physicians have indicated that his in-service chest pain was due to pectus excavatum, rather than ischemic heart disease. As detailed above, service connection is not warranted for pectus excavatum, thus any claim for heart disease on a secondary basis pursuant to § 3.310 has no legal merit. In sum, the Board finds that, without any objective medical evidence showing heart disease, to include CAD, myocardial infarction, and atrial fibrillation, during service or within a year after the Veteran's discharge, or any competent medical evidence relating the Veteran's currently diagnosed heart disease to any incident of service. The Board acknowledges the medical treatise evidence submitted by the Veteran pertaining to pectus excavatum and heart problems and electrocardiograms. The Board notes that medical treatise evidence can, in some circumstances, constitute competent medical evidence. See 38 C.F.R. § 3.159(a)(1) (competent medical evidence may include statements contained in authoritative writings such as medical and scientific articles and research reports and analyses). The Court has held that a medical article or treatise "can provide important support when combined with an opinion of a medical professional" if the medical article or treatise evidence discussed generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least "plausible causality" based upon objective facts rather than on an unsubstantiated medical opinion. Sack v. West, 11 Vet. App. 314 (1998); see also Wallin v. West, 11 Vet. App. 509 (1998) (medical treatise evidence discussed generic relationships with a degree of certainty to establish a plausible causality of nexus), and Mattern v. West, 12 Vet. App. 222, 228 (1999). In this case, an opinion was obtained pertaining to his pectus excavatum and heart disease, and the June 2012 VA examiner specifically opined that his pectus excavatum is a defect, and opined that any heart sounds, coronary artery disease, myocardial infarction, and atrial fibrillation are not due to his pectus excavatum and are not due to service. Moreover, the medical treatise evidence submitted does not provide support for a relationship between the Veteran's pectus excavatum and a disability, including heart disease, nor does the evidence provide support for a relationship between his current heart disease and service. Thus, such treatise cannot provide the basis for service connection. The Board has considered the Veteran's contentions pertaining to his pectus excavatum and heart disease. In this capacity, the Board finds the Veteran is competent to attest to his recollections during service and thereafter pertaining to his symptomatology. However, he is not competent to provide an opinion regarding the etiology of his pectus excavatum and heart disease, as he does not have the requisite medical expertise. The questions involved regarding causation are medical in nature. As discussed above, the medical opinion of the VA medical examiner (based on a review of the service treatment records and post-service treatment records) was negative. Under these circumstances, the Board is unable to find that there is a state of equipoise of the positive evidence and negative evidence. The preponderance of the evidence now of record is against the Veteran's claim of service connection for heart disease, to include CAD, MI, and atrial fibrillation. In reaching this decision, the Board has considered the doctrine of reasonable doubt. However, as the preponderance of the evidence is against the Veteran's claim, the doctrine is not for application. 38 U.S.C.A. § 5107(b); see also, e.g., Ortiz, 274 at 1364-5; Gilbert, 1 Vet. App. at 49. Seizure disorder The Veteran asserts that he suffered a head injury while he was in the military. He contends that due to his head injury, he later developed a seizure disorder. Service treatment records, including his January 1973 ETS examination, are negative for complaints or findings of a head injury or a seizure disorder. The Veteran, however, is competent as a layperson to report that on which he has personal knowledge, which would include the claimed in-service head injury. Thus, the Board accepts as true that the Veteran injured his head during service. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Post-service medical records reflect that a seizure disorder occurred in September 2002. The private medical records show that in September 2002 the Veteran was treated for syncope. He stated that he was walking to his truck when he started shaking all over and passed out. Per the Veteran, he awoke in the hospital confused and experiencing headaches. He was diagnosed with seizures and was prescribed medication. In August 2013, a Veterans Health Administration (VHA) neurologist reviewed the Veteran's claims folders. The Board notes that the Veteran reported a non-penetrating head injury while in service, claiming that he was "knocked out" in training "for a few seconds." The examiner acknowledged that his first seizure was in September 2002 at age 50, approximately 30 years after his head injury. The examiner noted no prior history of seizures and no other history of head trauma, other than that in service. He has also had no history of stroke. The examiner commented that an MRI did not show mesial temporal sclerosis or other focal abnormality as what can be seen in partial secondarily generalized epilepsy. However, the MRI was not done with contrast and it was unclear if it was done as a "seizure protocol" which allows better analysis of potential epileptogenic areas. An EEG revealed focal epileptiform activity in the left hemisphere. As the Veteran has no other history of head injury or trauma, and no history of stroke, the examiner opined that it is more likely than not that his seizures at the age of 50 were due to his prior head trauma, even though it was minor and many years later, as seizures can develop decades after head trauma. In light of the Veteran's credible assertions pertaining to sustaining a head injury during service and the positive etiological opinion from the August 2013 VHA examiner which relates his seizure disorder to the in-service head injury, the Board finds the preponderance of evidence supports a finding that a seizure disorder is related to active service. (CONTINUED ON NEXT PAGE) ORDER Entitlement to service connection for pectus excavatum (a bony deformity of the sternum or breast bone) is denied. Entitlement to service connection for coronary artery disease, myocardial infarction, and atrial fibrillation, to include as due to pectus excavatum, is denied. Entitlement to service connection for a seizure disorder is granted. ____________________________________________ ERIC S. LEBOFF Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs