Citation Nr: 1337120 Decision Date: 11/14/13 Archive Date: 11/26/13 DOCKET NO. 04-27 621 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Hartford, Connecticut THE ISSUES 1. Entitlement to service connection for macules on the tongue. 2. Entitlement to service connection for chronic bronchitis. 3. Entitlement to service connection for asthma. 4. Entitlement to service connection for chronic sinusitis. 5. Entitlement to service connection for a chronic heart disorder manifested by a heart murmur. 6. Entitlement to service connection for bilateral pes planus. 7. Entitlement to service connection for a chronic low back disorder. 8. Entitlement to service connection for a psychiatric disorder, to include posttraumatic stress disorder (PTSD) and a bipolar disorder. 9. Entitlement to an initial evaluation in excess of 10 percent for hypertension. REPRESENTATION Appellant represented by: Connecticut Department of Veterans Affairs WITNESS AT HEARINGS ON APPEAL Appellant ATTORNEY FOR THE BOARD Tresa M. Schlecht, Counsel INTRODUCTION The Veteran served on active duty from January 1989 to July 2003. This appeal initially came before the Board of Veterans' Appeals (Board) from February 2004 and December 2005 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Hartford, Connecticut. In pertinent part, the Board remanded the issues remaining on appeal in July 2008, in October 2011, and in January 2013. The Veteran testified at a videoconference hearing at the RO in January 2008, before the undersigned Acting Veterans Law Judge of the Board. A transcript of the hearing is associated with the claims file. The Veteran had previously testified at a personal hearing before the RO in February 2007. In May 2013, the Veteran's representative requested a 30-day extension of time in which to submit additional evidence and argument. By a letter issued in September 2013, the Board granted that extension. The 30 days allowed for extension of time to submit argument or evidence has expired. Appellate review may proceed. Following the Board's January 2013 decision, the claim for service connection for hypertension was granted. The Veteran has disagreed with the assigned initial rating, and that claim is remanded. The claims files and electronic files (Virtual VA) available to the Board do not reflect that an SOC has been issued in response to the disagreement. An SOC must be issued. Manlincon v. West, 12 Vet. App. 238 (1998). Unfortunately, additional development remains for the issues of entitlement to service connection for a chronic low back disorder and for service connection for a psychiatric disorder, to include posttraumatic stress disorder (PTSD) and a bipolar disorder, and the claim for an increased (compensable) initial evaluation for hypertension. Those claims 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. Hyperpigmented macules on the Veteran's tongue and inside the mouth are asymptomatic, consistent with normal variation, do not result in functional impairment, and are not a disability for which service connection is authorized. 2. The Veteran's symptoms since service separation do not meet the diagnostic criteria for assignment of a diagnosis of chronic bronchitis. 3. No diagnosis or history of asthma was noted at the time of the Veteran's examination or history at service induction, but the Veteran was treated for asthma in service and has continued to require recurrent, if intermittent, treatment for asthma post-service. 4. The findings and the Veteran's symptoms since service separation do not meet the diagnostic criteria for assignment of a diagnosis of chronic sinusitis. 5. The findings and the Veteran's symptoms do not meet the diagnostic criteria for assignment of a diagnosis of a chronic heart disorder manifested by a heart murmur. 6. The Veteran's bilateral pes planus was described as mild at the time of her entry into service and as moderate, requiring arch support, at her service discharge. CONCLUSIONS OF LAW 1. The criteria for service connection for service connection for macules on the tongue are not met. 38 U.S.C.A. §§ 1110, 1111, 1153, 5103, 5103A, 5107(b) (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309 (2013). 2. The criteria for service connection for service connection for chronic bronchitis are not met. 38 U.S.C.A. §§ 1110, 1111, 1153, 5103, 5103A, 5107(b) (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309 (2013). 3. Asthma was incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1111, 1153, 5103, 5103A, 5107(b) (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309 (2013). 4. The criteria for service connection for service connection for chronic sinusitis are not met. 38 U.S.C.A. §§ 1110, 1111, 1153, 5103, 5103A, 5107(b) (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309 (2013). 5. The criteria for service connection for service connection for a chronic heart disorder manifested by a heart murmur are not met. 38 U.S.C.A. §§ 1110, 1111, 1153, 5103, 5103A, 5107(b) (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309 (2013). 6. Bilateral pes planus was aggravated by service. 38 U.S.C.A. §§ 1110, 1111, 1153, 5103, 5103A, 5107(b) (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran contends that she is entitled to service connection for the claimed disorders. Duties to Notify and Assist VA has a duty to notify and a duty to assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. §§ 3.159, 3.326(a). Proper notice from VA must inform the claimant and his representative, if any, prior to the initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ) of any information and any 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 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). There is no requirement to discuss the duties to notify and assist regarding the claims for service connection for asthma, and pes planus granted in this decision. Claims underlying this appeal have been pending for nearly 10 years. During this period, the Veteran has received numerous communications from VA, including letters issued in September 2003, February 2005, May 2005, March 2006, June 2009, and December 2009, which advised the Veteran of some or all elements of a service connection claim. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In addition to letters specifically intended to meet the duty to notify, the Veteran was sent a statement of the case (SOC) and supplemental statements of the case (SSOCs), among other communications issued over the course of the 10 years of the pendency of this appeal. The claims on appeal have been readjudicated following the Board's Remands in July 2008, in October 2011, and in January 2013, in the SSOCs issued prior to each transfer and recertification of this case to the Board. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). The most recent SSOC was issued in April 2013. Here, neither the Veteran nor her representative has alleged prejudice with respect to notice. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009); Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Goodwin v. Peake, 22 Vet. App. 128 (2008); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). The Board finds that no defect in the timing or content of notice to the Veteran is apparent from the record. The Veteran's communications demonstrate that she received notice regarding relevant evidence. VA also has a duty to assist the Veteran in obtaining evidence necessary to substantiate a claim. 38 U.S.C.A. § 5103A(a) ("The Secretary shall make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate the . . . claim"). This duty includes assisting the Veteran in obtaining records and providing medical examinations or obtaining medical opinions when such are necessary to make a decision on the claim. 38 U.S.C.A. § 5103A(b), (c), (d) (setting forth Secretary's various duties to claimant). Lengthy VA clinical records are associated with the claims file. Electronic records are associated with the claims files. The Veteran's Social Security Administration (SSA) have been obtained and reviewed. The Veteran also submitted additional records and written statements in support of her claims. Service personnel records and certain service treatment records, primarily a 1989 service induction examination and a 2003 separation examination, are of record. The Veteran's service treatment records remain incomplete, despite several attempts by VA to obtain them. Notably, the Board remanded this claim in July 2008 and again in October 2011 for the agency of original jurisdiction (AOJ) to ascertain the existence of any outstanding service treatment records, but no additional records have been located. As to the claims addressed on the merits in this decision, the Board notes that any reasonable doubt related to the absence of service treatment records has been resolved in the Veteran's favor. No determination on the merits in this decision could be more favorable to the Veteran if service treatment records were located. The Veteran is not prejudiced by the lack of additional service treatment records. Specific VA medical examinations to determine the nature and etiology of each of the disorders addressed on the merits in this decision were obtained, including VA examinations in October 2010 and review and addendum in March 2013. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. The Board finds that these examinations of record are adequate for the determinations below, as the examinations were based on a review of the entire claims file, consideration of the lay testimony of record, and clinical examinations and testing where necessary. In 2008, the Veteran testified before the undersigned by Videoconference. An individual who chairs a Veteran's hearing before the Board must fulfill two duties: (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. 38 C.F.R. § 3.103(c)(2); Bryant v. Shinseki, 23 Vet. App. 488 (2010). In this case, the issues remaining on appeal were identified during the Veteran's 2008 Videoconference hearing before the Board. The Veteran's testimony as to the history, in-service treatment, and post-service treatment of each claimed disorder on appeal was elicited. The undersigned directed the Veteran's attention to the evidence missing and the unsubstantiated elements of each of the claims on appeal. See Transcript (Tr.) January 2008 BVA Videoconference hearing, pages 5-33. The Board notes that there was no perfected appeal of a claim for TDIU at the time of the 2008 hearing; that claim was inferred later. The duties under 38 C.F.R. § 3.103 have been met. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist in the development of the claim. 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). The Veteran has suffered no prejudice that would warrant a remand, and her procedural rights have not been abridged. See Bernard v. Brown, 4 Vet. App. 384 (1993). The Board will therefore proceed with the adjudication of this appeal. Relevant Laws and Regulations, Claims for Service Connection Service connection will be granted if it is shown that the Veteran suffers from a disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in the line of duty, during active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Disorders diagnosed after discharge will still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d); see also Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). To establish service connection, there must be: (1) a medical diagnosis of a current disability; (2) medical or, in certain cases, lay evidence of in-service occurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between an in-service injury or disease and the current disability. Hickson v. West, 12 Vet. App. 247, 252 (1999) (citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996)). Where a Veteran has served for 90 days or more during a period of war, or during peacetime service after January 1, 1947, and a chronic disorder, such as diabetes mellitus, becomes manifest to a degree of 10 percent within one year from the date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. In this case, several claims for service connection are on appeal. Some of the disorders at issue are defined by statute or regulation as chronic; others are not defined at chronic under the applicable statutory and regulatory provisions. 38 U.S.C.A. § 1101; 38 C.F.R. § 3.309(a). The provisions authorizing presumptive service connection for chronic diseases are addressed further below. Lay testimony is competent regarding features or symptoms of injury or disease when the features or symptoms are within the personal knowledge and observations of the witness. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). 1. Claim for service connection for macules on the tongue The Veteran's December 1988 examination for entry into service includes no notation regarding pigmentation inside the mouth. The service treatment records disclose no complaints about pigmentation of the mouth or treatment of pigmentation in the mouth. The July 2003 report of separation examination notes that the examiner found hyperpigmented macules on the tongue. The Veteran reported that the hyperpigmented areas had been present for three years. The Board notes, for purposes of information only, that the term " macule" is defined as a circumscribed flat area up to 1.0 cm in diameter perceptibly different in color from the rest of the ear, neither elevated nor depressed. Stedman's Medical Dictionary 1053 (27th ed. 2000). On VA examination conducted in October 2010, the appearance of hyperpigmented areas on the tongue and inner cheeks was noted. Color photographs were completed and have been associated with the claims files. The examiner noted that there was no interference with mastication, there was no functional impairment, and no there was no disfigurement resulting from the macules, although the macules are visible on inspection of the tongue. The examiner concluded that, as likely as not, the hyperpigmented macules were a congenital abnormality, Peutz-Jegher's syndrome, which was no exacerbated by service. Peutz-Jegher's syndrome is defined as caused by an autosomal dominant mutation of chromosome 19p resulting in benign polyps in the intestinal tract and melanin spots on the lips and buccal mucosa. Stedman's Medical Dictionary 1763 (27th ed. 2000). In a March 2013 addendum, the examiner noted that the hyperpigmented macules in the Veteran's mouth could be the result of smoking and use of birth control pills, if not due to Peutz-Jaegers syndrome. The examiner stated that the lesions were asymptomatic, and had been asymptomatic since onset. The examiner indicated that there was no evidence of advancement of the lesions, if congenital, and noted that, if the lesions were due to smoking, smoking cessation would as likely as not resolve the condition. The examiner noted that, when seen in VA Dental Clinic in February 2013, the Veteran had generalized pigmented macules on the oral mucosa, including the tongue and gingiva, consistent with normal anatomic variation. At her 2008 hearing before the Board, the Veteran testified that she wanted to undergo biopsy to make sure that she did not have cancer. She noted that her providers wanted her to have a biopsy while she was in the military, but her service ended before she could get a biopsy done. The clinical providers who submitted reports of VA examination in 2010 and 2013 did not suggest that a biopsy was required or recommended, and the lengthy VA treatment records do not reflect that any provider has recommended a biopsy. Given the opinions provided by the examiners and providers, and the color photographs available for review in the claims files, the Board concludes that the Veteran's hyperpigmentation of small areas inside her mouth is essentially the equivalent of an abnormal laboratory finding rather than a disorder with objective symptomatology resulting in industrial impairment. Since the pigmentation changes are not visible in a general industrial setting, and are consistent with "normal anatomic variation," the macules are not disfiguring. The macules are asymptomatic and have required no evaluation or treatment. Therefore, the Board concludes that the hyperpigmentation of small areas on the Veteran's tongue and buccal mucosa are not a disability for VA purposes. See 38 C.F.R. §§ 4.1, 4.10; 61 Fed. Reg. 20,440, 20,445 (May 7, 1996) (diagnoses such as hyperlipidemia, elevated triglycerides, and elevated cholesterol are not, in and of themselves, disabilities, and are not appropriate entities for the rating schedule). The Board notes that, if the pigmentation variations on the Veteran's tongue and buccal mucosa become symptomatic, require treatment, or begin to result in disfigurement or industrial impairment, such facts would be new and material to reopen the claim. However, at this time, the pigmentation variations observable in the Veteran's mouth does not result in disfigurement, since the area is not visible except under circumstances when the Veteran opens her mouth wide and sticks out her tongue during medical examination. The macules cause no symptoms and require no medical care. Although the Veteran has discussed obtaining a biopsy of the pigmented areas, there is no notation that providers plan to perform a biopsy. The areas of hyperpigmentation are not visible during ordinary employment tasks, so the pigmentation does not result in industrial impairment. In the absence of any symptom or industrial impairment, there is no disability. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (holding that Congress has specifically limited entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability). Service connection for the Veteran's hyperpigmented macules is not authorized under the law and regulations governing benefits administered by VA. The Board concludes that the preponderance of the evidence is against the Veteran's claim. There is no doubt to be otherwise resolved. As such, the appeal is denied. 2. Claim for service connection for chronic bronchitis The Veteran's December 1988 examination for entry into service includes no notation regarding a pre-existing respiratory disorder. The Veteran's service treatment records have not been located. In the portion of the separation medical history completed by the Veteran, she stated she was treated for wheezing during service and had breathing problems associated with exercise beginning in 2000. She stated that an inhaler has been prescribed beginning in 2003. In September 2006, the Veteran sought treatment for shortness of breath, pleuritis pain, a dry cough, and wheezing. The Veteran provided a past history of asthma and allergic rhinitis. An upper respiratory infection and asthma were the assigned diagnoses, and the Veteran was treated for each diagnosis. Pulmonary function testing in November 2006 disclosed moderate air obstruction. At her February 2007 personal hearing, the Veteran testified that she still required treatment for bronchitis as well as asthma and sinusitis. She stated that she required different antibiotics depending on whether she had bronchitis or sinusitis. February 2007 RO Transcript (RO Tr.) at 15. VA outpatient treatment records disclose that, in July 2011, the Veteran sought renewal of her prescription for Atrovent nebulizer. The provider noted that the Veteran had not been seen by VA for respiratory evaluation since 2009. The Veteran reported that she had been using a nebulizer since 2007. The Veteran was provided with one refill of medication and advised that evaluation was required. Detailed records of the Veteran's VA inpatient and residential facility treatment in 2012 (283 pages of electronic records dated in 2012 are associated with the record) reflect that the Veteran was treated for asthma, but not for bronchitis. An October 2012 VA outpatient treatment note reflects that the Veteran's asthma was stable with no indication of exacerbations. At the time of the October 2010 VA examination, the Veteran reported recurrent episodes of mucous production lasting about two weeks at a time. The examiner who conducted the 2010 examination concluded that the Veteran may have been treated for isolated episodes of bronchitis in service, or since service, but did not manifest bronchitis at the time of the 2010 examination. The examiner concluded that the Veteran had isolated upper respiratory tract infections and bronchitis, but not chronic bronchitis, after service. In the February 2013 addendum, the examiner explained that chronic bronchitis is clinically defined as chronic cough with production of sputum for three months, two years in a row. VA treatment records disclose no period of treatment for three months or more for bronchitis or increased sputum or congestion since the Veteran's service discharge in 2003. The examiner also found it significant that the list of all medications prescribed by VA after the Veteran's service discharge, which is associated with the electronic file and is approximately 60 pages in length, discloses no evidence that medication for treatment of acute or chronic bronchitis has been dispensed by VA during the period of the pendency of this appeal. The examiner's rationale and discussion of the factual basis for a determination that the Veteran does not meet the criteria for a diagnosis of chronic bronchitis is persuasive. The fact that no medication has been dispensed by a VA pharmacy for treatment of bronchitis since the Veteran's service discharge in 2003 is persuasive evidence that the Veteran does not currently have chronic bronchitis. To the extent that the Veteran has had bronchitis at any time since her service discharge, that bronchitis resolved in less than three months. The Board finds that determinations as to whether manifestations of bronchitis represent acute or chronic disorders are matters that require medical expertise. The Veteran is not shown to have a acquired expertise as to this matter and her opinions as to the nature of her respiratory symptoms are not competent evidence. The persuasive evidence establishes that the Veteran does not currently have chronic bronchitis. The evidence further reflects that the Veteran has not met the criteria for a diagnosis of chronic bronchitis at any time during the appeal period. The preponderance of the evidence is against the claim. There is no reasonable doubt. The claim for service connection for chronic bronchitis must be denied. 3. Claim for service connection for asthma The Veteran's December 1988 examination for entry into service includes no notation regarding a pre-existing respiratory disorder. The Veteran's service treatment records have not been located. Treatment for respiratory disorders was noted at the time of the Veteran's separation examination, including on the history provided by the Veteran. At her February 2007 personal hearing, the Veteran testified that she still required treatment for asthma, bronchitis, and sinusitis. She stated that she required different antibiotics depending on whether she had asthma or bronchitis or sinusitis. February 2007 RO Transcript (RO Tr.) at 15. The examiner who conducted a VA examination in 2010 concluded that the Veteran had asthma prior to her service, because one of the few records available, a dental examination, reflects that the Veteran provided a history of "asthma as a child." She also stated that her "last attack" was in March 1988. As she was inducted into service in January 1989, that "attack" would have been prior to her service. One of the few records from the Veteran's service which has been located is a dental history provided by the Veteran. In that report, the Veteran provided a history of "asthma as a child." She also stated that her "last attack" was in March 1988. The Veteran's separation examination, dated in July 2003, reflects that the Veteran reported "breathing problems associated w/exercise 2000." She reports that an inhaler was prescribed in 2003. She reported 1990 and 2000 emergency room visits for treatment of asthma. VA outpatient treatment records dated in October 2011 reflect that the Veteran was using a nebulizer, with medication, ipatropium. For purposes of information, the Board notes that ipatropium (trade names Atrovent, Apovent, Ipraxa, Aerovent and Rinatec) is an anticholinergic drug used for the treatment of chronic obstructive pulmonary disease and acute asthma. It blocks the muscarinic acetylcholine receptors in the smooth muscles of the bronchi in the lungs, opening the bronchi. Dorland's Illustrated Medical Dictionary 972 (31st ed. 2007). The VA providers did not assign a diagnosis of a respiratory disorder other than asthma. In October 2012, the VA outpatient treatment provider noted that the Veteran had been given refills of her asthma nebulizer three times since 2008, most recently in May 2012. The Veteran's asthma was described as stable, with no indication of exacerbations. On VA examination conducted in 2010, the examiner concluded that the Veteran had asthma prior to her service, and that the asthma was not permanently aggravated in service. In October 2012, the VA outpatient treatment provider noted that the Veteran had been given refills of her asthma nebulizer three times since 2008, most recently in May 2012. The Veteran's asthma was described as stable. The examiner who provided a 2013 addendum noted that the Veteran was treated for exercise-induced asthma and has required at least intermittent treatment of asthma since her service discharge. The examiner noted that the Veteran had a long history of smoking, which began early in her service. The examiner concluded that it was as likely as not that the Veteran had asthma prior to service which was intermittently exacerbated due to exercise, smoking, substance abuse, and viral illnesses, both during service and after. The Board concludes that the medical opinions require a grant of service connection. Both examiners concluded that it was as likely as not that the Veteran had asthma prior to service. However, no diagnosis of asthma was made at the time of the Veteran's service entry examination, and there is no indication that the Veteran had episodes of exercise-induced asthma prior to service. There is no record that the Veteran required treatment for asthma prior to service. Although the Veteran reported, on at least two occasions, that she had "asthma" prior to service, the Veteran's lay statement that she had "asthma," without more detail, or medical records of the treatment prior to service, does not rebut the presumption of soundness on entry. 38 U.S.C.A. § 1111; Crowe v. Brown, 7 Vet. App. 238 (1994) (lay history of pre-service existence of a disorder does not constitute a notation of such condition at entry into service). The Veteran, who served during a period of wartime, must be presumed sound on entry unto service, unless that presumption is rebutted. 38 U.S.C.A. § 1111. The providers who indicated that the Veteran had asthma at the time of service induction did not opine that this evidence was so significant as to constitute clear and convincing evidence of pre-service asthma. As such, the presumption of soundness is not rebutted. When the presumption is not rebutted, the claim is considered on a direct incurrence basis. See Wagner, 370 F.3d at 1094, 1096 (indicating that, in cases where the presumption of soundness cannot be rebutted, the effect is that claims for service connection based on aggravation are converted into claims for service connection based on service incurrence). The Board further notes that, even where the presumption of soundness is rebutted, VA must rebut the presumption of aggravation in service, where the claimed disorder was treated during service, by clear and unmistakable evidence that an injury or disease manifested in service was both preexisting and not aggravated by service. Wagner, 370 F.3d at 1096. The medical opinions of record establish that this burden of proof is not met. The most persuasive evidence of record, including the 2003 separation examination and both VA medical opinions, establishes that the Veteran was treated for asthma in service. The presumption of soundness at entry has not been rebutted. Because the Veteran was treated in service for asthma and still requires treatment for asthma on a recurring, if intermittent basis, the criteria for service connection are met. The claim for service connection for asthma must be granted. 4. Claim for service connection for chronic sinusitis The Veteran's December 1988 examination for entry into service includes no notation regarding any disorder of the respiratory system or a history of sinusitis. The Veteran's July 2003 separation examination reflects that the Veteran reported that she was treated for sinusitis in 2002 and required antibiotics. VA outpatient treatment records from the date of the Veteran's 2005 claim for service connection for sinusitis to the date of the 2010 VA examination file to disclose that the Veteran sought VA treatment for sinusitis or that radiologic examination of the sinuses was ordered by any provider. On VA examination in December 2010, the examiner found no objective evidence of sinusitis. The examiner noted the Veteran's report that she used antihistamines related to seasonal allergies rather than sinusitis. The examiner concluded that the Veteran had episodic respiratory illnesses that resolved, but did not have chronic sinusitis. VA treatment records reflect that the Veteran sought an appointment for treatment of "sinusitis" in September 2010. However, the Veteran could not be seen immediately. The evidence does not thereafter show that the Veteran was treated for sinusitis. In the February 2013 addendum, the examiner explained that chronic sinusitis is defined as a sinus infraction that persists for 3 months or more. The VA treatment records disclose no period of treatment for three months or more for sinusitis since the Veteran's service discharge in 2003. In particular, the examiner noted that the Veteran had several hospitalizations, including lengthy VA hospitalizations, and no diagnosis of sinusitis was noted. The examiner also found it significant that the list of all medications prescribed by VA after the Veteran's service discharge, which is associated with the electronic file and is approximately 60 pages in length) discloses no evidence that medication for treatment of acute or chronic sinusitis was dispensed by VA. The examiner's rationale and discussion of the factual basis for a determination that the Veteran does not meet the criteria for a diagnosis of chronic sinusitis is persuasive. The fact that no medication has been dispensed by a VA pharmacy for treatment of sinusitis since the Veteran's service discharge in 2003 is persuasive evidence that the Veteran does not currently have chronic sinusitis. To the extent that the Veteran has had sinusitis at any time since her service discharge, that sinusitis resolved. The Board finds that determinations as to whether manifestations of sinusitis represent acute or chronic disorders are matters that require medical expertise. The Veteran is not shown to have a acquired expertise as to this matter and her opinions as to the nature of her sinus symptoms are not competent evidence. The evidence establishes that the Veteran does not currently have chronic sinusitis. The evidence further reflects that the Veteran has not met the criteria for a diagnosis of chronic sinusitis at any time during the appeal period. The preponderance of the evidence is against the claim. There is no reasonable doubt. The claim for service connection for chronic sinusitis must be denied. 5. Claim for service connection for heart disorder manifested by murmur The Veteran's December 1988 examination for entry into service includes no notation regarding a heart murmur. No records of the Veteran's treatment in service are available. The Veteran's 2003 separation examination notes "prob innocent murmur." The Veteran sought service connection for a heart murmur. A murmur was detected at the time of VA admission in 2008, but cardiac echocardiograms conducted in January 2007 and in 2008 revealed normal right and left ventricular systolic functions, no significant valvular disease, and mild left ventricular hypertrophy with grade 1 diastolic dysfunction. The Veteran denied such symptoms as angina. The examiner who conducted October 2010 VA examination concluded that the Veteran had an innocent murmur. The Veteran contended that a heart murmur could never be considered "innocent." In 2013, the reviewer provided clarification that the Veteran had no cardiac valvular abnormality. The reviewer explained that an "innocent" murmur is a murmur which is detected where there is an absence of any valvular structural or other abnormality. The reviewer concluded that the Veteran did not currently manifest a disorder related to a heart murmur. The detailed records of the Veteran's treatment, including more than 300 pages of treatment records for 2012, disclose that the Veteran has not been treated for any cardiac disorder or symptomatology other than hypertension. The Veteran has provided lay statements regarding chronicity and continuity of such symptoms and difficulty breathing and rapid heartbeat. While the Veteran is competent to state that she experiences difficulty breathing and rapid heartbeat, she is not competent to state the cause of these symptoms. Davidson v. Shinseki, 581 F.3d at 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (whether lay evidence is competent and sufficient in a particular case is a factual issue to be addressed by the Board). As the Veteran testified at her hearing before the Board, she knew she had a rapid heartbeat and difficulty breathing, but she did not know whether this was due to a heart murmur, asthma, or some other cause. However, the medical evidence does not link difficulty breathing or rapid heartbeat to a heart murmur noted in service. As noted above, sophisticated diagnostic examinations, including echocardiogram, have been conducted to determine the underlying cause of a heart murmur. No objective medical disorder or valvulular abnormality or structural cause for a murmur has been found. As the Veteran has been granted service connection for hypertension and asthma, the symptomatology and treatment of hypertension and asthma cannot serve as the factual basis to warrant service connection for a heart murmur. To the extent that hypertension or asthma may cause difficulty breathing or rapid heartbeat, service connection for those symptoms is in effect. The medical evidence establishes that the Veteran does not manifest disability due to a heart murmur, and does not manifest a valvular abnormality, and no cardiac disorder other than hypertension has been identified. In the absence of disability due to a heart murmur or identification of any disorder underlying a heart murmur, service connection for a heart murmur or a cardiac disorder manifested by a heart murmur is not authorized. The preponderance of the evidence is against the Veteran's claim. There is no doubt to be otherwise resolved. As such, the appeal is denied. 6. Claim for service connection for bilateral pes planus If a pre-existing disability is noted upon entry into service, the Veteran cannot bring a claim for service connection for that disability, but the Veteran may bring a claim for service-connected aggravation of that disability. 38 U.S.C.A. § 1111; see Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). The Veteran may establish service connection if there was an increase in disability during service. 38 U.S.C.A. § 1153; see Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004); Jensen v. Brown, 19 F.3d 1413, 1417 (Fed. Cir. 1994). In this case, bilateral pes planus, "mild, asymptomatic," was noted at the time of the Veteran's entry into service. The presumption of soundness does not apply as to the claim for this disorder. 38 U.S.C.A. § 1111. At the time of service separation in 2003, pes planus, "mod[erate], needs arch support," was noted. The examiner who conducted 2010 VA examination concluded that pes planus was not aggravated in service because the Veteran reported no chronic foot complaints. However, at her 2008 hearing before the Board, the Veteran reported chronic foot pain and inability to wear certain types of shoes because the shoes cause increased foot pain. In a 2013 addendum to the 2010 VA examination reported, the reviewer commented that the Veteran gained weight during service. The reviewer stated that, given the circumstances of the Veteran's weight gain, the progression of pes planus in service was the expected natural progression. The reviewer further commented that the Veteran increased foot pain since service was the result of additional weight gain since service. Since the Veteran had a pre-existing pes planus, the increased disability reflected in the change from the description at service entry of "mild" pes planus to the description of "moderate" at service separation is presumed to constitute aggravation. The reviewer's comment that the Veteran's weight gain during service led to the "natural progression" of the disorder is, in effect, an opinion that the bilateral pes planus increased in severity during the Veteran's service, since the weight gain occurred in service and is not attributed to misconduct. Given the presumption of aggravation in 38 U.S.C.A. § 1153, the Board finds that, although the reviewer's opinion appears unfavorable to the claim for service connection for pes planus, that opinion is favorable to the claim when interpreted in light of the legal presumption applicable in this case. The claim for service connection for pes planus as aggravated in service must be granted. ORDER The appeal for service connection for macules on the tongue is denied The appeal for service connection for chronic bronchitis is denied. The appeal for service connection for asthma is granted. The appeal for service connection for chronic sinusitis is denied. The appeal for service connection for a chronic heart disorder manifested by a heart murmur is denied. The appeal for service connection for bilateral pes planus is granted. REMAND Claim for service connection for a chronic low back disorder The examiner who conducted VA examination in 2010 concluded that the Veteran had a compression deformity of L1, of unknown onset. The examiner opined that the Veteran might have incurred that deformity in August 2005 when she was retrained due to violent behavior. However, the only record associated with the Veteran's claims files with regard to an August 2005 hospitalization is a September 2005 VA examination report which reflects that the Veteran recently eloped from an inpatient unit at 8-West where she had been admitted for bipolar disorder. The examiner did not discuss any examination of the Veteran's lumbar spine post-service until October 2010. The October 2010 VA examination report is not an adequate basis upon which to evaluate the examiner's conclusion. More complete records of the Veteran's VA treatment in 2005 should be obtained, and an effort should be made to locate any reports of VA or private examination of the Veteran's lumbar spine prior to 2010. As the Veteran was hospitalized several times following her service separation, an effort should be made to determine whether there are any examinations of the lumbar spine prior to 2010. Claim for service connection for a psychiatric disorder The Veteran's separation examination discloses that she was treated for alcohol abuse during service. The only available clinical record prior to the Veteran's June 2003 service separation is a VA psychiatric evaluation in early February 2000. She reported unspecified stressors at work, and expressed anxiety about getting appropriate treatment on base due to confidentiality concerns. The Veteran's personnel records reflect that she incurred her first nonjudicial punishment in February 2000 soon after the VA emergency visit. The Board is unable to find an indication that psychiatric treatment records which may be separately-filed have been sought. A further attempt to obtain psychiatric records is required. In March 2005, about two years after her service separation, the Veteran sought VA treatment for alcohol and substance abuse. At that time, the provider concluded, based on the Veteran's behavior patterns, that she manifested bipolar disorder in service, prior to developing alcohol dependence. The examiner who conducted November 2010 VA examination concluded that the Veteran's only psychiatric disorder was PTSD. The examiner opined that the Veteran no longer met the criteria for assignment of a diagnosis of bipolar disorder, and that bipolar disorder is frequently misdiagnosed when interpreting addiction-related behaviors, of which the Veteran had a long history. The examiner also opined that the Veteran's PTSD was due to sexual trauma during service, and that the Veteran's alcohol abuse was secondary to her PTSD. In light of the conflicting medical evidence, an additional examination is required. Claim for increased rating for hypertension As noted in the Introduction, above, the Veteran is entitled to an SOC addressing her disagreement with the initial 10 percent rating assigned for hypertension. Accordingly, the case is REMANDED for the following action: 1. Provide the Veteran and her representative with a statement of the case regarding the claim of entitlement to an increased (compensable) initial rating for hypertension. They should be advised of the time period in which to perfect an appeal on the matter. If, but only if, the Veteran perfects a timely appeal, the claim for an increased initial evaluation for hypertension should then be returned to the Board for further appellate consideration. 2. The RO should ask the National Personnel Records Center (NPRC) or Records Management Center, as appropriate, to search again for service treatment records for the Veteran, to include inpatient or outpatient service treatment records, clinic records, or other medical records, to include separately-filed psychiatric or alcohol treatment records, to include records held by or retired from the Drug and Alcohol Prevention Administration (DAPA), as well as from the hospital or associated facilities which provided care for personnel at the Naval and Marine Corps Center, Greensboro, North Carolina, from 1997 to March 1998, and for the hospital or associated health care facilities for the Naval and Marine Corps Center, Fort Schuyler, Bronx, New York, during the period from April 1998 to December 2000, and for hospital or associated health care facilities for the Naval Reserve Readiness Command Midwest, Great Lakes, Illinois, from December 2000 through 2003. A search should also be conducted to determine if there is a separately-filed Uniform Code of Military Justice file for the Veteran. 3. Afford the Veteran an opportunity to identify any other evidence that might be available to substantiate her claims on appeal. 4. Ask the Veteran if she recalls any examination of her lumbar spine by any private treatment provider after her June 2003 service separation prior to VA examination of the lumbar spine in October 2010. If the Veteran is able to identify a provider who may have conducted radiologic examination of the Veteran's back, including during outpatient, emergency, or inpatient treatment, during the relevant period, those records should be sought. 5. Attempt to locate the Veteran's complete inpatient treatment records for any VA hospitalization in 2005, including the records of an August 2005 VA admission. 6. Obtain the Veteran's complete radiologic examinations folder, including the reports of all radiologic examinations prior to October 2010. Associate records of any examination of the spine or chest prior to October 2010 with the claims file or the electronic record. 7. After the development conducted above is completed, an updated medical opinion as to the etiology and date of onset of the Veteran's current lumbar disorder should be obtained, with consideration of all pertinent evidence of record. 8. The Veteran should be afforded VA examination to determine the current nature and etiology of the Veteran's psychiatric disorders, to include disability manifest for any identifiable period of time during this appeal. The examiner should review the Veteran's claim for service connection for an acquired psychiatric disorder, to include review of the transcript of a hearing before the RO conducted in February 2007 (Vol. 2 of the claims files) and the transcript of a videoconference hearing before the Board conducted in January 2008 (Vol. 3 of the claims files). The examiner should review the historical records, to include personnel records, for evidence that tends to corroborate the occurrence of a personal assault which the Veteran contends occurred in June 1998 during military service. In performing such review, the examiner must clearly identify the particular records which are felt to provide corroboration of the incident, and must give an adequate rationale for why it is felt that such records establish that a personal assault actually occurred during military service. Any necessary psychological or diagnostic testing should be conducted. After conducting review of the results of necessary testing, examination of the Veteran, and review of the relevant portions of the claims files, the examiner should assign a diagnosis for each psychiatric disorder the Veteran currently manifests. In particular, the examiner should provide an opinion as to whether the Veteran has symptomatology that meets the diagnostic criteria for bipolar disorder or PTSD. The examiner should list all of the Veteran's psychiatric disorders in accordance with DSM-IV. If a diagnosis of PTSD is assigned, the examiner must identify the stressor(s) underlying the diagnosed PTSD, and provide an opinion as to whether it is at least as likely as not (a 50 percent or greater likelihood) that PTSD was either first manifested during service or is etiologically related to the Veteran's service or any incident therein. If a diagnosis of bipolar disorder is assigned, the examiner should provide an opinion as to whether it is at least as likely as not (a 50 percent or greater likelihood) that bipolar disorder was either first manifested during the Veteran's service and has continued since that time. The examiner must provide a comprehensive report including complete rationales for all opinions and conclusions reached. If a requested opinion cannot be provided without resort to mere speculation, indicate this in the examination report and explain why speculation is required. 9. If a benefit sought on appeal remains denied, provide the Veteran and her representative with a supplemental statement of the case and the opportunity to respond thereto. Thereafter, subject to current appellate procedure, the case should be returned to the Board for further consideration, if in order. The appellant has the right to submit additional evidence and argument on the matter or 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). ______________________________________________ T. L. Douglas Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs