Citation Nr: 1749640 Decision Date: 11/02/17 Archive Date: 11/13/17 DOCKET NO. 13-18 130 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to service connection for a heart condition, to include as due to herbicide agent exposure. 2. Entitlement to service connection for a bilateral leg condition. 3. Entitlement to service connection for a lung condition. 4. Entitlement to service connection for a prostate condition, to include as due to herbicide agent exposure. 5. Entitlement to service connection for an intestinal condition, to include colon adenocarcinoma, and as due to herbicide agent exposure. 6. Entitlement to service connection for hypertension. 7. Entitlement to service connection for a nervous condition. 8. Entitlement to service connection for a sleep condition, diagnosed as sleep apnea. ATTORNEY FOR THE BOARD S. Owen, Associate Counsel INTRODUCTION The Veteran served on active duty from July 1966 to July 1968, with a period of service in the Republic of Vietnam. The Veteran received the Air Medal and Combat Medic Badge, among other decorations, for this service. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2012 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, Puerto Rico, which granted service connection for a back condition and vision condition, evaluated as 20 percent and 10 percent disabling, respectively, and denied service connection for a bilateral leg condition, lung condition, sleeping condition, heart condition, hypertension, intestinal condition, prostate condition, and nervous condition. In June 2012, the Veteran filed a timely notice of disagreement (NOD) with the ratings assigned for the service-connected conditions, the denial of service connection claims, and raised an additional issue of individual unemployability. In June 2012, the RO also found that the issue of bilateral lower extremity radiculopathy had been raised by the record. In a June 2013 rating decision, the RO denied increased rating claims for the back and vision conditions, denied service connection for bilateral lower extremity radiculopathy, and denied individual unemployability. The RO also issued a statement of the case (SOC) for the claims of service connection for a bilateral leg condition, lung condition, sleeping condition, heart condition, hypertension, intestinal condition, prostate condition, and nervous condition. In June 2013, the Veteran filed VA Form 9 (Appeal to the Board of Veterans' Appeals) asking to continue the appeal for the June 2013 SOC and disagreeing with the June 2013 rating decision. In December 2016, the RO issued a supplemental statement of the case (SSOC) for the claims of service connection for a bilateral leg condition, lung condition, sleeping condition, heart condition, hypertension, intestinal condition, prostate condition, and nervous condition. The RO issued a SOC for the increased ratings claims for back and vision conditions, service connection for bilateral lower extremity radiculopathy, and individual unemployability. The Veteran has not filed a VA Form 9 (Appeal to the Board of Veterans' Appeals) nor has he otherwise perfected an appeal on the claims of increased ratings for back and vision conditions, service connection for bilateral lower extremity radiculopathy, and individual unemployability. The Board further notes that the RO only completed a VA Form 8 (Certification of Appeal) only for the claims included on the December 2016 SSOC. Therefore, the issues of the back, vision, lower extremity radiculopathy and TDIU are not before the Board. In order to serve the Veteran's stated interests, the Board has broadened the Veteran's nervous condition claim as a claim of entitlement to service connection for an acquired psychiatric disorder. Clemons v. Shinseki, 23 Vet. App. 1 (2009) (per curium). This appeal was processed using the Virtual VA and Veterans Benefits Management System (VBMS) paperless claims processing system. Accordingly, any future consideration of this case should take into consideration the existence of this electronic record. The issues of entitlement to service connection for a prostate condition, intestinal condition, hypertension, acquired psychiatric disorder, and sleep apnea are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The evidence of record does not reflect that the Veteran has a currently diagnosed heart condition, to include ischemic heart disease. 2. The evidence of record does not reflect that the Veteran has a currently diagnosed bilateral leg condition. 3. The evidence of record does not reflect that the Veteran has a currently diagnosed lung condition. CONCLUSIONS OF LAW 1. The criteria for the establishment of service connection for a heart condition have not been met. 38 U.S.C.A. §§ 1101, 1110,1111, 1112, 1113, 1116, 1137, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2017). 2. The criteria for service connection for a bilateral leg condition have not been met. 38 U.S.C.A. §§ 1101, 1110, 1111, 1112, 1113, 1137, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2017). 3. The criteria for service connection for a lung condition have not been met. 38 U.S.C.A. §§ 1101, 1110, 1111, 1112, 1113, 1116, 1137, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5103, 5013A, 5106, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2017). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative 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). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The Veteran was advised of VA's duties to notify and assist in the development of the claim at issue by notice letter dated in February 2012. See 38 U.S.C.A. §§ 5102, 5103, 5103A (West 2014); 38 C.F.R. § 3.159 (2016); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). The VCAA also provides that VA has a duty to assist claimants in obtaining evidence needed to substantiate a claim. 38 U.S.C.A. § 5103A; 38 C.F.R § 3.159(c). Here, the Veteran's service records, VA records, and private treatment records identified by the Veteran have been obtained and associated with the claims file. With regards to the Veteran's claimed heart condition, the Veteran was afforded a VA examination in May 2012. The examination is of record. To that end, when VA undertakes to either provide an examination or to obtain an opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The VA examination report reflects that relevant records were reviewed and the examiner personally interviewed and examined the Veteran, including eliciting a history from him, and offered opinions. The record shows that the Veteran has not been afforded a VA compensation and pension medical examination in connection with the claims of service connection for a bilateral leg condition and lung condition. The Board finds that such an examination or a medical opinion is not necessary in this case. As will be discussed in greater detail below, the evidence of record is sufficient in order to make a proper determination in this case. The Veteran has been afforded a meaningful opportunity to participate effectively in the processing of the claim, including by submission of statements and arguments. Based upon the foregoing, the duties to notify and assist the Veteran have been met, and no further action is necessary to assist the Veteran in substantiating this claim. Service Connection Laws and Regulations Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection generally requires (1) evidence of a current disability; (2) evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The U.S. Court of Appeals for Veterans Claims (Court) has held that "Congress specifically limits entitlement to service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability, there can be no valid claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). A veteran, who had active service in the Republic of Vietnam during the period beginning on January 9, 1962 and ending on May 7, 1975, will be presumed to have been exposed to an herbicide agent during such service unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. See 38 U.S.C.A. § 1116(f) (West 2014); 38 C.F.R. § 3.307(a)(6)(iii) (2016). "Service in the Republic of Vietnam" includes service in the waters offshore and service in other locations if the conditions of service involved duty or visitation in the Republic of Vietnam. 38 C.F.R. § 3.307(a)(6)(iii). In order to establish qualifying "service in Vietnam," a veteran must demonstrate actual duty or visitation in the Republic of Vietnam. Pursuant to the authority granted by the Agent Orange Act of 1991, VA may determine that a presumption of service connection based on exposure to herbicides used in Vietnam is warranted for conditions that VA has found to have a statistically significant association with such exposure. As such, VA has determined that a statistically significant association exists between exposure to herbicides and subsequent development of the following conditions: chloracne or other acneform disease consistent with chloracne, non-Hodgkin's lymphoma, soft tissue sarcoma, Hodgkin's disease, porphyria cutanea tarda (PCT), multiple myeloma, acute and subacute peripheral neuropathy, prostate cancer, cancers of the lung, bronchus, larynx, trachea, Type II (adult-onset) diabetes mellitus, chronic lymphocytic leukemia, AL amyloidosis, Parkinson's disease, ischemic heart disease, and B-cell leukemias, such as hairy cell leukemia. See 38 C.F.R. § 3.309(e). Ischemic heart disease does not include hypertension or peripheral manifestations of arteriosclerosis such as peripheral vascular disease or stroke. Id. at note 3. The diseases listed at § 3.309(e) shall have become manifest to a degree of 10 percent or more at any time after service, except that chloracne or other acneform disease consistent with chloracne, porphyria cutanea tarda, and acute and subacute peripheral neuropathy shall have become manifest to a degree of 10 percent or more within a year after the last date on which the veteran was exposed to an herbicide agent during active military, naval, or air service. 38 C.F.R. § 3.307(a)(6)(ii). VA regulations specify that the last date on which a veteran shall be presumed to have been exposed to an herbicide agent shall be the last date on which he or she served in the Republic of Vietnam during the period beginning on January 9, 1962 and ending on May 7, 1975. 38 C.F.R. § 3.307(a) (6)(iii). VA's Secretary has determined that a presumption of service connection based on exposure to herbicides used in the Republic of Vietnam during the Vietnam era is not warranted for any condition for which the Secretary has not specifically determined a presumption of service connection is warranted. See 68 Fed. Reg. 27,630 (May 20, 2003). Nevertheless, presumptions of service connection are not intended to limit service connection to that basis of entitlement when the evidence warrants direct service connection. 38 C.F.R. § 3.303(d) (2016). Direct service connection may be granted for disease or disability diagnosed in service; or, if diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. Id. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. It may also include statements conveying sound medical principles found in medical treatises. Competent medical evidence may also include statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Lay assertions may serve to support a claim for service connection by establishing the occurrence of observable events or the presence of a disability or symptoms of disability subject to lay observation. 38 U.S.C.A. § 1154(a) (West 2014); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). Lay evidence can be competent and sufficient to establish a diagnosis or etiology when (1) a lay person is competent to identify a medical condition; (2) the lay person is reporting a contemporaneous medical diagnosis; or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the veteran. See 38 U.S.C.A. § 5107 (West 2014); 38 C.F.R. § 3.102 (2016). Analysis The Veteran's DD 214 reflects that he had active service from July 1966 to July 1968, with more than 11 months in the Republic of Vietnam. Therefore, in-service exposure to herbicide agents is conceded. Heart condition The Veteran contends that service connection is warranted for a heart condition, to include as due to herbicide agent exposure. On a November 1965 entrance examination, the Veteran denied chest pain or pressure, palpitations, dizziness or vertigo, and high or low blood pressure. Upon objective examination, his heart and vascular system were found normal, with a blood pressure reading of 112/66. On a May 1968 separation examination, the Veteran reported palpitation or pounding heart, but denied pain or pressure in his chest, dizziness or vertigo, and high or low blood pressure. Upon objective examination, the Veteran's heart and vascular system were found normal, with a blood pressure reading of 100/68. The Veteran's service treatment records are otherwise silent with regards to complaints of or treatment for a heart condition. The Veteran was afforded a VA examination in May 2012. The examiner noted that the Veteran denied having suffered any myocardial infarction, having angina, or having suffered any cardiac event. The examiner found that the Veteran did not have ischemic heart disease, myocardial infarction, or congestive heart failure. Based on the Veteran's responses, the examiner found that a METs of >7-10 was appropriate. An EKG and x-ray were performed, revealing no evidence of cardiac hypertrophy or dilatation. Treatment records reflect that the Veteran has continued to deny a cardiovascular problem and the Veteran's heart had a regular rhythm, with no murmurs, clicks, or gallops. See April 2014 and July 2016 Virtual VA CAPRI records. Direct service connection requires a currently diagnosed disability and the Veteran's treatment records and VA examination do not reflect that the Veteran has a diagnosed heart condition, to include ischemic heart disease. In the absence of proof of a current disability, there can be no valid claim. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); see Degmetich v. Brown, 104 F. 3d 1328 (1997). Congress has specifically limited entitlement to service connection to cases where such incidents have resulted in a disability. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Although the Veteran self-reported having had heart palpitations or pounding on his separation examination, the Veteran's heart was found to be normal on objective examination. Therefore, direct service connection is not warranted. Further, the Board notes that there is no current diagnosis of ischemic heart disease, and as such the presumptions related to herbicide exposure, which apply in cases of ischemic heart disease, are for application. 38 C.F.R. § 3.309(a), (e). The May 2012 VA examiner established, after a review of the record and examination of the Veteran, that there is no ischemic heart disease in this case. The examiner's findings as to this matter are the most probative evidence as they are based on a thorough review and are explained. A lay person is competent to establish a diagnosis in the following circumstances: (1) the medical issue is within the competence of a layperson, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d at 1376-77. In this case, a diagnosis of ischemic heart disease is a complex finding that goes beyond the mere observation of symptoms by a lay person--in other words, the clinical pathology of a heart disorder is not readily recognizable by a layman. Thus, the lay evidence here does not establish current disability in this case. The preponderance of the evidence indicates that the Veteran does not have a currently diagnosed heart condition, to include ischemic heart disease. As the preponderance of the evidence is against the claim of service connection for a heart condition, the benefit-of-the-doubt doctrine does not apply, and the claim must be denied. 38 U.S.C.A. § 5107 (West 2014); 38 C.F.R. § 3.102 (2016). Bilateral leg condition The Veteran contends that service connection is warranted for a bilateral leg condition. The Board notes that the Veteran has previously filed a claim for bilateral lower extremity radiculopathy which was adjudicated separately from the Veteran's claim for a bilateral leg condition, and an appeal was not perfected on the radiculopathy claim. As such, the Board is only reviewing the claim for a bilateral leg condition on appeal. On a November 1965 entrance examination, the Veteran denied inflamed or painful joints; knee cramps; arthritis, bone, joint, or other deformity; painful or crippled knee; limp, loss of legs; or foot disorder. Upon objective examination, his lower extremities and feet were found normal. On a May 1968 separation examination, the Veteran denied swollen or painful joints; arthritis; bone, joint, or other deformity; lameness, loss of leg; trick or locked knee; or foot trouble. Upon objective examination, the Veteran's lower extremities and feet were found normal. The Veteran's service treatment records are otherwise silent with regards to complaints of or treatment for a bilateral leg condition. The Veteran's post-service treatment records are silent for complaints of or treatment for a leg condition. The Veteran's extremities have been found normal, with no clubbing, cyanosis, edema, skin discoloration, trauma, ulcers or callus. Range of motion has been intact, muscle tone adequate, and with no deformities of the musculoskeletal system. See April 2014 and July 2016 Virtual VA CAPRI records. The Veteran has not been afforded a VA examination in connection with this claim. However, there is no evidence of a current bilateral leg condition and there is no competent evidence suggesting that any current condition is related to service. Accordingly, a VA examination and opinion is not required. 38 C.F.R. § 3.159(c)(4); see McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also Walker v. Shinseki, 601 F.3d 1274, 1278 (Fed. Cir. 2010) (noting that a conclusory lay statement that a current condition is related to service is insufficient to warrant a medical examination because it would "eliminate the carefully drafted statutory standards governing the provision of medical examinations and require the Secretary to provide such examinations in virtually every veteran's disability case"). The preponderance of the evidence indicates that the Veteran does not have a current bilateral leg condition. As the preponderance of the evidence is against the claim of service connection for a bilateral leg condition, the benefit-of-the-doubt doctrine does not apply, and the claim must be denied. 38 U.S.C.A. § 5107 (West 2014); 38 C.F.R. § 3.102 (2016). Lung condition The Veteran contends that service connection is warranted for a lung condition. On a November 1965 entrance examination, the Veteran denied whooping cough, tuberculosis, asthma, or difficulty breathing. Upon objective examination, his lungs and chest were found normal. On a May 1968 separation examination, the Veteran denied tuberculosis, asthma, shortness of breath or chronic cough. Upon objective examination, the Veteran's lungs and chest were found normal. The Veteran's service treatment records are otherwise silent with regards to complaints of or treatment for a lung condition. Post-service treatment records reflect that the Veteran's bilateral breath sounds were clear to auscultation and he denied shortness of breath. See September 2012, January 2013, July 2016 Virtual VA CAPRI records. No lung conditions have been noted in recent medical assessments. See April 2014 and July 2016 Virtual VA CAPRI records. The Veteran has not been afforded a VA examination in connection with this claim. However, there is no evidence of a current lung condition and there is no competent evidence suggesting that any current condition is related to service. Accordingly, a VA examination and opinion is not required. 38 C.F.R. § 3.159(c)(4); see McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also Walker v. Shinseki, 601 F.3d 1274, 1278 (Fed. Cir. 2010) (noting that a conclusory lay statement that a current condition is related to service is insufficient to warrant a medical examination because it would "eliminate the carefully drafted statutory standards governing the provision of medical examinations and require the Secretary to provide such examinations in virtually every veteran's disability case"). The preponderance of the evidence indicates that the Veteran does not have a current lung condition. As the preponderance of the evidence is against the claim of service connection for a lung condition, the benefit-of-the-doubt doctrine does not apply, and the claim must be denied. 38 U.S.C.A. § 5107 (West 2014); 38 C.F.R. § 3.102 (2016). ORDER Entitlement to service connection for a heart condition, to include ischemic heart disease, and as due to herbicide agent exposure, is denied. Entitlement to service connection for a bilateral leg condition is denied. Entitlement to service connection for a lung condition is denied. REMAND Prostate condition The Veteran contends that service connection is warranted for a prostate condition, to include as due to herbicide agent exposure. The Veteran was afforded a VA examination in May 2012. The examiner noted that the Veteran received his medical treatment in the private sector but that when asked, the Veteran denied having been diagnosed with a prostate cancer condition or having been evaluated for such a condition. Upon examination, the examiner found that the Veteran did not have a voiding dysfunction, erectile dysfunction, retrograde ejaculation, history of urinary tract infections, surgical scars or residuals from prostate cancer treatment. The examiner concluded that there were no significant diagnostic test findings and/or results. Post-service treatment records reflect that the Veteran's prostate-specific antigen (PSA) has increased from 0.988ng/mL in October 2013, to 3.580ng/mL in March 2015, to 1.090ng/mL in August 2015, to 5.300ng/mL in June 2016 and the Veteran indicated he was going to obtain a prostate examination from his private physician. See July 2016 Virtual VA CAPRI records. As the record is not clear whether the Veteran has a current prostate condition and there may be outstanding private medical records, the Board finds that a remand is warranted in order to obtain outstanding medical records and a VA examination and medical opinion as to the nature and etiology of any diagnosed prostate condition. The Board notes that the duty to assist is not always a one-way street, or a blind alley, and that the Veteran must be prepared to cooperate with the VA's efforts to provide an adequate medical examination. See Olson v. Principi, 3 Vet. App. 480, 483 (1992). Any outstanding and pertinent VA treatment records and any private treatment records identified by the Veteran should be obtained and associated with the Veteran's electronic claims file. The most recent VA treatment records associated with the Veteran's claims file are from December 2016. Intestinal condition The Veteran contends that service connection is warranted for an intestinal condition, to include as due to herbicide agent exposure. On a November 1965 entrance examination, the Veteran denied hernia, appendicitis, hemorrhoids. Upon objective examination, his abdomen, viscera; anus, and rectum were found normal. In June 1967, the Veteran reported with abdominal pains and cramps in his mid to lower abdomen. The Veteran was prescribed donnital and told to return if needed. On a May 1968 separation examination, the Veteran denied frequent indigestion; stomach, liver, or intestinal trouble; gall bladder trouble; appendicitis; rupture or hernia; and piles or rectal disease. Upon objective examination, the Veteran's abdomen, viscera, anus, and rectum were found normal. The Veteran's service treatment records are otherwise silent with regards to complaints of or treatment for an intestinal condition. The Veteran was afforded a VA examination in April 2012. The examiner noted that the Veteran was diagnosed with colon adenocarcinoma in 2006 and underwent surgical removal. The Veteran reported he had remained stable based on a follow-up colonoscopy. The examiner found that the Veteran's adenocarcinoma was not caused by or the result of his abdominal complaints in service. The Board finds that the April 2012 VA examiner's opinion is inadequate, as the examiner did not provide a basis or rationale for his opinion. Furthermore, the examiner did not consider whether the Veteran's colon adenocarcinoma was caused by or the result of his exposure to herbicide agents in Vietnam on a direct basis. Therefore, the Board finds that a remand is warranted for a VA addendum opinion, which addresses the nature and etiology of the Veteran's intestinal condition, to include colon adenocarcinoma. Hypertension The Veteran contends that service connection is warranted for hypertension, claimed as high blood pressure. On a November 1965 entrance examination, the Veteran denied chest pain or pressure, palpitations, dizziness or vertigo, and high or low blood pressure. Upon objective examination, his heart and vascular system were found normal, with a blood pressure reading of 112/66. On a May 1968 separation examination, the Veteran reported palpitation or pounding heart, but denied pain or pressure in his chest, dizziness or vertigo, and high or low blood pressure. Upon objective examination, the Veteran's heart and vascular system were found normal, with a blood pressure reading of 100/68. The Veteran's service treatment records are otherwise silent with regards to complaints of or treatment for a heart condition. The Veteran was afforded a VA examination in April 2012. The examiner noted that the Veteran was diagnosed with high blood pressure in 1985, but opined that the Veteran's hypertension was not caused by or a result of his military service, as there was no relationship with the Veteran's complaints in the claims folder. The Board finds that the April 2012 VA examiner opinion is in adequate, as the examiner did not provide a basis or rationale for the opinion. As such, the Board finds that a remand is warranted for a new opinion that addresses the nature and etiology of the Veteran's diagnosed hypertension. In addition, the Veteran's VA treatment records reflect that the Veteran was receiving non-VA treatment for his diagnosed hypertension. See January 2013 and July 2016 CAPRI records. These private treatment records have not been associated with the Veteran's electronic claims file; therefore, the Board cannot review them as part of the record on appeal. On remand, an attempt should be made to obtain and associate these private treatment records with the Veteran's electronic claims file. Acquired psychiatric disorder The Veteran contends that service connection is warranted for a nervous disorder. In order to serve the Veteran's stated interests, the Board has broadened the Veteran's nervous condition claim as a claim of entitlement to service connection for an acquired psychiatric disorder. Clemons v. Shinseki, 23 Vet. App. 1 (2009) (per curium). On a November 1965 entrance examination, the Veteran denied a nerve disorder and upon objective examination, the Veteran's psychiatric assessment was normal. On the Veteran's May 1968 separation examination, he reported that he had previously or currently had nervous trouble, but denied depression or excessive worry. The Veteran was afforded a VA examination in April 2012. The examiner noted that the Veteran reported seeking treatment from a private psychiatrist in 2006 and that he had occasional mild to moderate anxiety since then. The examiner found that the Veteran did not have a diagnosed mental disorder. In a letter dated in June 2012, the Veteran's treating physician stated that the Veteran presented with episodes of excessive anxiety and worry, including difficulty concentrating, irritability, decreased interest and pleasure in activities, depressed mood, and altered sleep. The Veteran reported flashbacks of traumatic incidents he had at war, with hypervigilance and inability to tolerate loud sounds. The Veteran's physician opined that it was at least as likely as not that his has a nervous condition that was due to his duties while in service. It is not clear whether the Veteran has a diagnosed psychiatric disorder that is related to his active duty service. Therefore, the Board finds that a remand is warranted so that a VA examination and medical opinion can be obtained as to the nature and etiology of any diagnosed psychiatric disorder. The Board notes that records associated with the Veteran seeking psychiatric treatment in 2006 and those from his treating physician have not been associated with the Veteran's electronic claims file; therefore, the Board cannot review them as part of the record on appeal. On remand, an attempt should be made to obtain and associate these private treatment records with the Veteran's electronic claims file prior to obtaining a new VA examination and medical opinion. Sleep apnea The Veteran contends that service connection is warranted for a sleep condition, diagnosed as sleep apnea. On a November 1965 entrance examination, the Veteran denied constant insomnia or frequent nightmares. Upon objective examination, his nose, sinuses, mouth and throat were found normal. In May, June, and July 1968, the Veteran was diagnosed with laryngitis and reported with tonsillitis and a sore throat. On a May 1968 separation examination, the Veteran reported ear, nose, or throat trouble but denied frequent trouble sleeping or frequent and terrifying nightmares. The examiner noted that the Veteran reported a sore throat and that his throat was always irritated. Upon objective examination, the Veteran's nose, sinuses, mouth, and throat were found normal. The Veteran's service treatment records are otherwise silent with regards to complaints of or treatment for a sleep condition. The Veteran's post-service treatment records reflect that he has been diagnosed with mild obstructive sleep apnea, mild hypopnea, mild hypoxemia, and primary snoring hypersomnia. See April 2014 VA treatment records. The Veteran has not been afforded a VA examination in connection with his claim for a sleep condition, diagnosed as sleep apnea. A VA examination is required where the record includes (1) competent evidence of a current disability or continuous symptoms since service; (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies; and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with a Veteran's service or with another service-connected disability; and (4) lack of sufficient competent evidence upon which the Board can decide the claim. See 38 U.S.C.A. § 5103A(d) (West 2014); 38 C.F.R. § 3.159(c)(4)(i) (2016); see also McLendon v. Nicholson, 20 Vet. App. 79 (2006). Therefore, the Board finds that a remand is warranted in order to obtain a VA examination and medical opinion that addresses the nature and etiology of the Veteran's claimed sleep condition, diagnosed as sleep apnea. Accordingly, the case is REMANDED for the following actions: 1. Obtain and associate with the Veteran's electronic claims file any VA treatment records since December 2016 and any private records identified by the Veteran pertaining to the claims remanded herein, to include private treatment records identified by the Veteran for hypertension and an acquired psychiatric disorder. 2. Then, schedule the Veteran for a VA examination to determine the nature and etiology of any diagnosed prostate condition. The record and a copy of this remand must be made available to the examiner for review, and the examiner must specifically acknowledge receipt and review of these materials in any reports generated. The examiner must take a detailed history from the Veteran. If there is any clinical or medical basis for corroborating or discounting the reliability of the history provided by the Veteran, the examiner must so state, with complete explanation in support of such a finding. The examiner must provide an opinion as to (a) Whether it is at least as likely as not (50 percent or greater possibility) that the Veteran has a diagnosed prostate condition. (b) If the examiner finds that the Veteran has a diagnosed prostate condition, the examiner must provide an opinion as to whether it is at least as likely as not (50 percent or greater possibility) that any diagnosed prostate condition began during or is caused by active service, to include exposure to herbicide agents in Vietnam; or began within one year after discharge from active service. Although a thorough review of the claims file is required, the Board draws the examiner's attention to the July 2016 VA treatment records that reflect increased levels of PSA. The examiner must provide a comprehensive report including complete rationales for all opinions and conclusions, based on his or her clinical experience, medical expertise, and established medical principles. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and specifically explain whether there is any potentially available information that, if obtained, would allow for a non-speculative opinion to be provided. The examiner is advised that the term "as likely as not" does not mean within the realm of possibility. Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is medically sound to find in favor of causation as to find against causation. More likely and as likely support the causal relationship. Less likely weighs against the claim. 3. Return the Veteran's electronic claims file to the April 2012 VA examiner to determine the nature and etiology of the Veteran's intestinal condition, to include colon adenocarcinoma. If the examiner is unavailable, the claims file must be provided to an examiner who is qualified to give an opinion on the Veteran's intestinal condition, so that a new opinion may be provided. A new examination is only required if deemed necessary by the examiner. The record and a copy of this remand must be made available to the examiner for review, and the examiner must specifically acknowledge receipt and review of these materials in any reports generated. If a new examination is conducted, the examiner must take a detailed history from the Veteran. If there is any clinical or medical basis for corroborating or discounting the reliability of the history provided by the Veteran, the examiner must so state, with complete explanation in support of such a finding. The examiner must provide an opinion as to whether it is at least as likely as not (50 percent or greater possibility) that the Veteran's intestinal condition, to include colon adenocarcinoma, began during or is caused by active service, to include exposure to herbicide agents in Vietnam; or began within one year after discharge from active service. The examiner must provide a comprehensive report including complete rationales for all opinions and conclusions, based on his or her clinical experience, medical expertise, and established medical principles. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and specifically explain whether there is any potentially available information that, if obtained, would allow for a non-speculative opinion to be provided. The examiner is advised that the term "as likely as not" does not mean within the realm of possibility. Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is medically sound to find in favor of causation as to find against causation. More likely and as likely support the causal relationship. Less likely weighs against the claim. 4. Return the Veteran's electronic claims file to the April 2012 VA examiner to determine the nature and etiology of the Veteran's hypertension. If the examiner is unavailable, the claims file must be provided to an examiner who is qualified to give an opinion on the Veteran's intestinal condition, so that a new opinion may be provided. A new examination is only required if deemed necessary by the examiner. The record and a copy of this remand must be made available to the examiner for review, and the examiner must specifically acknowledge receipt and review of these materials in any reports generated. If a new examination is conducted, the examiner must take a detailed history from the Veteran. If there is any clinical or medical basis for corroborating or discounting the reliability of the history provided by the Veteran, the examiner must so state, with complete explanation in support of such a finding. The examiner must provide an opinion as to whether it is at least as likely as not (50 percent or greater possibility) that the Veteran's hypertension, began during or is caused by active service; or began within one year after discharge from active service. The examiner must provide a comprehensive report including complete rationales for all opinions and conclusions, based on his or her clinical experience, medical expertise, and established medical principles. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and specifically explain whether there is any potentially available information that, if obtained, would allow for a non-speculative opinion to be provided. The examiner is advised that the term "as likely as not" does not mean within the realm of possibility. Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is medically sound to find in favor of causation as to find against causation. More likely and as likely support the causal relationship. Less likely weighs against the claim. 5. Schedule the Veteran for a VA examination to determine the nature and etiology of any diagnosed acquired psychiatric disorder. The record and a copy of this remand must be made available to the examiner for review, and the examiner must specifically acknowledge receipt and review of these materials in any reports generated. The examiner must take a detailed history from the Veteran. If there is any clinical or medical basis for corroborating or discounting the reliability of the history provided by the Veteran, the examiner must so state, with complete explanation in support of such a finding. The examiner must provide an opinion as to (a) Whether it is at least as likely as not (50 percent or greater possibility) that the Veteran has a diagnosed acquired psychiatric disorder. (b) If the examiner finds that the Veteran has a diagnosed acquired psychiatric disorder, the examiner must provide an opinion as to whether it is at least as likely as not (50 percent or greater possibility) that any diagnosed acquired psychiatric disorder began during or is caused by active service, to include any verified stressors experienced in Vietnam; or began within one year after discharge from active service. The examiner is asked to comment on a June 2012 letter from the Veteran's private physician. The examiner must provide a comprehensive report including complete rationales for all opinions and conclusions, based on his or her clinical experience, medical expertise, and established medical principles. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and specifically explain whether there is any potentially available information that, if obtained, would allow for a non-speculative opinion to be provided. The examiner is advised that the term "as likely as not" does not mean within the realm of possibility. Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is medically sound to find in favor of causation as to find against causation. More likely and as likely support the causal relationship. Less likely weighs against the claim. 6. Schedule the Veteran for a VA examination to determine the nature and etiology of his diagnosed sleep apnea. The record and a copy of this remand must be made available to the examiner for review, and the examiner must specifically acknowledge receipt and review of these materials in any reports generated. The examiner must take a detailed history from the Veteran. If there is any clinical or medical basis for corroborating or discounting the reliability of the history provided by the Veteran, the examiner must so state, with complete explanation in support of such a finding. The examiner must provide an opinion as to whether it is at least as likely as not (50 percent or greater possibility) that the Veteran's diagnosed sleep apnea began during or is caused by active service; or began within one year after discharge from active service. The examiner is asked to comment on the Veteran's in-service complaints of a sore throat. The examiner must provide a comprehensive report including complete rationales for all opinions and conclusions, based on his or her clinical experience, medical expertise, and established medical principles. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and specifically explain whether there is any potentially available information that, if obtained, would allow for a non-speculative opinion to be provided. The examiner is advised that the term "as likely as not" does not mean within the realm of possibility. Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is medically sound to find in favor of causation as to find against causation. More likely and as likely support the causal relationship. Less likely weighs against the claim. 7. After completing the above, and any other development as may be indicated, the Veteran's claims should be readjudicated based on the entirety of the evidence. If the claims remain denied, the Veteran and his representative should be issued a supplemental statement of the case (SSOC). An appropriate period of time should be allowed for response. Thereafter, the case should be returned to the Board for further appellate consideration, if otherwise in order. The appellant 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 2014). ______________________________________________ H. SEESEL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs