Citation Nr: 1802180 Decision Date: 01/11/18 Archive Date: 01/23/18 DOCKET NO. 14-02 206 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Louisville, Kentucky THE ISSUES 1. Whether new and material evidence has been received to reopen a previously denied service connection claim for posttraumatic stress disorder (PTSD). 2. Whether new and material evidence has been received to reopen a previously denied service connection claim for bipolar disorder. 3. Entitlement to service connection for an acquired psychiatric disability, to include posttraumatic stress disorder (PTSD) and bipolar disorder. 4. Whether new and material evidence has been received to reopen a previously denied service connection claim for hypertension. 5. Entitlement to service connection for hypertension. 6. Entitlement to service connection for bilateral tinnitus. 7. Entitlement to service connection for traumatic brain injury (TBI), to include headaches. 8. Entitlement to service connection for residuals of a salmonella infection, claimed as non-typhoid salmonella. 9. Entitlement to service connection for irritable bowel syndrome (IBS). 10. Entitlement to service connection for gastroesophageal reflux disease (GERD). REPRESENTATION Appellant represented by: James G. Fausone, Attorney at Law ATTORNEY FOR THE BOARD C. D. Simpson, Counsel INTRODUCTION The Veteran served on active duty for training (ACDUTRA) from September 2003 to January 2004 and active duty from November 2005 to December 2006 with service in Southwest Asia. He had additional service in the Army Reserves. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2011 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Louisville, Kentucky. In April 2012, the Veteran appointed James G. Fausone, Attorney at Law as his representative. The Board notes that the Veteran withdrew the issue of service connection for bilateral hearing loss in the January 2014 VA substantive appeal. It is not before the Board. 38 C.F.R. § 20.204. The Board has also recharacterized the underlying service connection claims for PTSD and bipolar disorder as a single claim for an acquired psychiatric disability, to encompass the additional psychiatric diagnoses raised by the record. See Clemons v. Shinseki, 23 Vet. App. 1, 4-5 (2009); see also October 2012 notice of disagreement. FINDINGS OF FACT 1. In a November 2007 decision, the RO denied the Veteran's claims of entitlement to service connection for hypertension, PTSD and bipolar disorder. The Veteran did not appeal that decision, and new and material evidence was not received within one year of its issuance. 2. Additional evidence received since the November 2007 RO decision is new to the record and considered with the record as a whole, is neither cumulative nor redundant as to the issues of entitlement to service connection for hypertension, PTSD and bipolar disorder, and raises a reasonable possibility of substantiating these claims. 3. The evidence is at least evenly balanced as to whether the Veteran has PTSD attributable to fear of hostile military activity from service in Iraq. 4. The evidence is at least evenly balanced as to whether the Veteran's bipolar disorder was incurred in service. 5. The evidence is at least evenly balanced as to whether the Veteran's hypertension was incurred in service or within the first post service year. 6. The evidence is at least evenly balanced as to whether tinnitus is related to in-service noise exposure. 7. The evidence is at least evenly balanced as to whether the Veteran has a current TBI from in-service blast exposure and blunt head trauma injury. 8. The evidence does not show that the Veteran has ever been diagnosed or suspected to have any residual disorder associated with an in-service salmonella infection. 9. The evidence does not show that the Veteran has ever been diagnosed or suspected to have IBS. 10. GERD did not have its onset in active service and is not otherwise related to service. CONCLUSIONS OF LAW 1. The November 2007 RO decision denying the claims of entitlement to service connection for hypertension, PTSD and bipolar disorder is final. 38 U.S.C. § 7105 (2012); 38 C.F.R. §§ 3.104, 20.302, 20.1103 (2017). 2. The evidence received since the November 2007 decision is new and material as to the issues of service connection for hypertension, PTSD and bipolar disorder and these claims are reopened. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (2017). 3. With reasonable doubt resolved in favor of the Veteran, an acquired psychiatric disability, to include PTSD and bipolar disorder, was incurred in active military service. 38 U.S.C. §§ 1110, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2017). 4. With reasonable doubt resolved in favor of the Veteran, hypertension was incurred in active military service. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 5. With reasonable doubt resolved in favor of the Veteran, tinnitus was incurred in active military service. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.303(b) 3.307, 3.309. 6. With reasonable doubt resolved in favor of the Veteran, the criteria for service connection for residuals of a TBI are met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303 (2017). 7. The criteria for entitlement to service connection for non-typhoid salmonella are not met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303. 8. The criteria for entitlement to service connection for IBS are not met. 38 U.S.C. §§ 1110, 1117, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303, 3.317 (2017). 9. The criteria for entitlement to service connection for GERD are not met. 38 U.S.C. §§ 1110, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist VA has met all statutory and regulatory notice and duty to assist provisions under the Veterans Claims Assistance Act of 2000 (VCAA). 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2017). The favorable rating actions for the PTSD, bipolar, hypertension, tinnitus and TBI claims result in a complete grant of the benefit sought. Discussion of VCAA compliance for these claims is not necessary. Pertinent to the non-typhoid salmonella, GERD and IBS claims, the RO's December 2010 notice letter advised the Veteran of the service connection elements prior to initial adjudication by the RO. See Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). Accordingly, the Board finds that the notification requirements of the VCAA have been satisfied. The Board also finds that there has been compliance with the assistance provisions set forth in the law and regulations. Some of the Veteran's service treatment records (STRs) are associated with the claims folder, as well as VA treatment records from February 2007 through 2014 as identified by the Veteran. The Board notes that service treatment records (STRs) from the Veteran's November 2005 to December 2006 deployment are incomplete and Louisville VA Medical Center (VAMC) records from January 2005 to January 2007 are missing. As indicated in the October 2007 and October 2011 RO Memorandums of Unavailability; see October 2007 and November 2011 notification letters, the RO took appropriate search and notifications for the missing records and further search efforts would be futile. 38 C.F.R. § 3.159(c)(2); see In such a case, the legal standard for proving a service connection claim remains unchanged. See Russo v. Brown, 9 Vet. App. 46 (1996); see Cromer v. Nicholson, 19 Vet. App. 215, 217-18 (2005) (wherein the Court declined to apply an "adverse presumption" where records have been lost or destroyed while in government control which would have required VA to disprove a claimant's allegation of injury or disease). The Board has taken into consideration the missing STRs and VAMC records and, as appropriate, granted several claims by employing the heightened consideration of the benefit-of-the-doubt standard to rely on the competent and credible lay reports of medical history and symptoms. See Cuevas v. Principi, 3 Vet. App. 542, 548 (1992); O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). The Board notes the Veteran reported being in receipt of Social Security Administration (SSA) disability benefits for PTSD. Neither the Veteran nor his attorney has indicated that these records are either pertinent to the salmonella, GERD or IBS claims and there is no other indication from the record that this evidence is relevant to these claims. Consequently, a remand to obtain these records is not warranted. Golz v. Shinseki, 590 F.3d 1317, 1321 (2010) (there is no duty to get SSA records when there is no evidence that they are relevant). He has not otherwise identified any additional relevant, outstanding records that need to be obtained before deciding these claims. Therefore, VA's duty to further assist the Veteran in locating additional records has been satisfied. See 38 U.S.C. § 5103A(d); see also 38 C.F.R. § 3.159 (c)(4) (2017). Neither the Veteran, nor his representative has raised any other issue with the duty to notify or duty to assist with respect to the service connection claims for GERD, IBS, or non-typhoid salmonella infection. See Scott v McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to duty to assist argument). II. New and Material Evidence In November 2007, the RO denied service connection for hypertension, PTSD and bipolar disorder. The Veteran did not appeal this decision and no new and material evidence was received within one year of this decision. As such, it became final. Bond v. Shinseki, 659 F.3d 1362, 1367-68 (Fed. Cir. 2011). As a general rule, a claim shall be reopened and reviewed if new and material evidence is presented or secured with respect to a claim that is final. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. Under 38 C.F.R. § 3.156(a), new evidence means existing evidence not previously submitted to agency decisionmakers. Material evidence means evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). In November 2007, the RO denied service connection for these claims due to an absence of a nexus to active service. Since the November 2007 RO decision, new evidence has been submitted. Army Reserve records showed that the Veteran continued to have hypertension and bipolar disorder following separation from active service. Then, in October 2012, the Veteran reported that he continued to experience anxiety, severe nightmares, irritability, and self-isolative behaviors. These reports indicate a continuity of symptomatology from when these claims were last adjudicated and weigh in favor of a nexus to service. As this evidence relates to the basis for the prior denial and raises a reasonable possibility of substantiating these claims, it is new and material. Reopening of the claims for service connection for hypertension, PTSD and bipolar disorder is therefore warranted. 38 C.F.R. § 3.156. III. Service connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Pursuant to 38 C.F.R. § 3.303(b), where a chronic disease is shown as such in service, subsequent manifestations of the same chronic disease, however remote, are service connected, unless clearly attributable to intercurrent causes. Continuity of symptomatology is required only where the condition noted during service is not in fact shown to be chronic or the diagnosis of chronicity may be legitimately questioned. The provisions of 38 C.F.R. § 3.303(b) apply only to the specific chronic diseases listed in 38 U.S.C. § 1101(3) and 38 C.F.R. § 3.309(a), which include tinnitus, psychosis and hypertension. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); Fountain v. McDonald, 27 Vet. App. 258, 271 (2015). The Board notes that the RO determined that STRs from November 2005 to December 2006 were incomplete. See October 2007 Formal Finding of Unavailability. It is highly likely a separation examination is part of these missing STRs. In instances of incomplete STRs, VA must employ heightened consideration of the benefit-of-the-doubt standard and rely on the competent and credible reports of medical history and symptoms. See Cuevas v. Principi, 3 Vet. App. 542, 548 (1992); O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). A. Acquired psychiatric disability, to include posttraumatic stress disorder (PTSD) and bipolar disorder In addition to the laws and regulations noted above, supplementary regulations govern PTSD claims. Service connection for post-traumatic stress disorder (PTSD) requires: (1) a medical diagnosis of PTSD utilizing, in this case, the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria, in accordance with 38 C.F.R. § 4.125(a); (2) credible supporting evidence that the claimed in-service stressor actually occurred; and (3) medical evidence of a causal nexus between current symptomatology and the specific claimed in-service stressor. See 38 C.F.R. § 3.304(f); Cohen v. Brown, 10 Vet. App. 128, 138 (1997). If a stressor claimed by a Veteran is related to that Veteran's fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of PTSD and that a Veteran's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of that Veteran's service, a Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304(f)(3). "[F]ear of hostile military or terrorist activity" means that a Veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the Veteran or others, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the Veteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. See id. The STRs do not show any complaints or treatment for any psychiatric disorder during active service. However, they include two pre-deployment medical evaluations from November 2005 and March 2006. In both evaluations, the Veteran denied any significant medical history. On both evaluations, the examining clinicians rated the Veteran as "1" in every category on the PULHES profile report. The "PULHES" profile report is an acronym that represents the profile's six categories: "P" stands for "physical capacity or stamina"; "U" stands for "upper extremities"; "L" stands for "lower extremities"; "H" stands for "hearing and ear"; "E" stands for "eyes"; and "S" stands for "psychiatric." A profile serial is assigned on a scale of 1 to 4 for each of the six categories, with "1" indicating the highest level of fitness. See Odiorne v. Principi, 3 Vet. App. 456, 457 (1992). Service records confirm that the Veteran served in Iraq from April 2006 to September 2006 in support of Operation Iraqi Freedom. His Military Occupational Specialty (MOS) is listed as an Armor Crewman. February 2007 VA primary care records were notable for complaints about irritability and feelings of isolation since returning from Iraq. An assessment of an adjustment disorder secondary to Iraq was made. The clinician referred the Veteran to the Mental Health Clinic (MHC). March 2007 VA MHC records reflected that the Veteran had served in Iraq and reported nightmares of intrusive combat thoughts that interfered with his work. He stated that he was constantly mortared while riding in convoy security. He avoided crowds and war news, as well as noises. He complained about irritability and destructive behavior. The VA psychiatrist diagnosed PTSD. April 2007 VA MHC records showed that the Veteran continued to have significant psychiatric symptoms, notably irritability, paranoia, nightmares, and low moods. The VA social worker diagnosed PTSD, Bipolar I manic type and adjustment disorder with mixed emotional stressors. In May 2007, the Veteran was afforded a VA PTSD examination. He complained about severe irritability that was partially improved with therapy. He reported anhedonia type symptoms and that his wife noticed a personality change since he had returned from Iraq. He complained that he was overworked during his deployment. Due to loss of consciousness episodes, he was medically evacuated from Iraq in September 2006. He had further evaluation for these episodes, but the medical diagnosis was not identified. Currently, he had difficulty controlling his irritability at work. For combat experience, the examiner noted that the Veteran's base was attacked by rockets and mortars on five to six occasions. The Veteran also reported working on convoys through combat zones in Iraq and characterized it as a stressful experience. Although he did not sustain fire, he believed some of the markings on his vehicles were from bullets. He also stated that the convoy unit was particularly careful to avoid improvised explosive devices (IEDs) and monitored civilians along the road for hostile activity. Psychiatric examination was notable for shaking lower extremities, fair mood, paranoid ideations, sleep disturbances, auditory hallucinations, inappropriate behavior, and obsessive/ ritualistic behaviors from daily car cleaning and yard mowing every other day. The examiner reported that the Veteran had severe paranoia and general poor adjustment since returning from Iraq. He noted the Veteran's military stressors. As relevant, the Veteran reported a mortar landing right outside his base and blowing debris and dust into his quarters. He witnessed five or six mortar attacks while in Iraq with one injury. He estimated he was as close as 50 yards to the explosion. He reported being scared and fearing for his life from these attacks. Quantitative testing suggested moderate PTSD. The examiner stated that the Veteran's reports of rocket and mortar attacks satisfied the PTSD stressor criterion. He diagnosed PTSD. September 2010 VA treatment records reflected that the Veteran was hospitalized for stability upon reports of severe irritability and poor impulse control. He had a recent medication change. The diagnosis was listed as intermittent explosive disorder and rule out bipolar disorder. May 2010 Reserve Medical Evaluation Board (MEB) records reflected that the Veteran had Bipolar II disorder. November 2010 VA MHC records showed that the Veteran continued to have severe irritability and poor impulse control. He acknowledged increased depression. The VA physician provided an assessment of PTSD, among other diagnoses. January 2011 Reserve records noted treatment for symptoms associated with anxiety, PTSD and bipolar disorder. The Veteran received a permanent psychological profile. In March 2011, the Veteran underwent an additional VA PTSD examination. The examiner noted the Veteran's psychiatric and alcohol abuse history. Since the 2007 VA examination, the Veteran had divorced his first wife and remarried. Currently, he worked part-time for his landlord. He was in the process of being medically discharged from the Reserves. Psychiatric examination was notable for sleep impairment, passive homicidal ideations, and violent episodes, described as hitting objects when consuming alcohol. The Veteran acknowledged being diagnosed with PTSD and bipolar disorder. However, he did not understand either diagnosis. He was currently unemployed. Since service, he had been fired from one job and laid off from another. The examiner diagnosed alcohol abuse in full early remission and rule out bipolar disorder, PTSD, among other diagnoses. He reported that the Veteran had a complex psychiatric picture. He believed the Veteran most likely had bipolar disorder, but expressed uncertainty concerning this diagnosis. He indicated alcohol abuse was associated with all diagnoses. He recommended an additional examination following twelve months of sobriety. He noted that the Veteran could not identify a military stressor for PTSD. He related the events in the 2007 VA examination as being accurate, but not particularly stressful. Some of the current symptoms suggested bipolar disorder, but did not conform to clinical guidelines and appeared to be better explained by heavy alcohol use. He expressed a negative medical opinion regarding the presence of PTSD citing the Veteran's current denial of a combat stressor event to meet the PTSD criterion A. In September 2011, a MEB determined that a recommendation for discharge from the Reserves was appropriate under a pre-military Bipolar Disorder diagnosis. In October 2012, the Veteran's wife reported that he had anxiety from crowds, severe nightmares, irritability episodes from minimal stimuli, and isolative behavior. May 2013 VA MHC records reflected that the Veteran sought treatment for anger and irritability. He reported that these problems started in 2006 when he returned from Iraq. A complete symptom inventory was taken. The examiner commented that the Veteran was deployed for six months in Iraq and was evacuated for loss of consciousness episodes that were not well understood. The Veteran reported being diagnosed with bipolar disorder, but questioned the accuracy of this diagnosis. He stated that his PTSD symptoms had dramatically increased over the past year. He stated that he received Social Security Administration (SSA) disability benefits for PTSD. He acknowledged his intermittent psychiatric treatment history, but reported that he was ready to seriously engage in treatment. He wanted to resume medication. He cited daily symptoms of startle response, irritability, anger outbursts, insomnia, nightmares, avoidance, concentration difficulties, fatigue and hypervigilance. The treating Social Worker assessed PTSD and bipolar disorder by report. The Veteran contends service connection is warranted for an acquired psychiatric disorder. The Board finds that the evidence is at least evenly balanced as to whether service connection for an acquired psychiatric disability, to include PTSD and bipolar disorder is warranted as explained below. Service department records confirm that the Veteran served in Iraq and his reports concerning fear of hostile military activity during mortar and rocket attacks are credible. The May 2007 VA examiner confirmed that such reports were satisfactory to substantiate a PTSD stressor and diagnosed PTSD. In November 2010, a VA psychiatrist continued the PTSD diagnosis. These reports on their face are highly probative evidence of current PTSD diagnosis and a nexus to fear of hostile military activity, as well as a relationship between other diagnosed psychiatric disorders and service. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); Romanowsky v. Shinseki, 26 Vet. App. 289, 293 (2013) (Board erred in failing to address pre-claim evidence in assessing whether a current disability existed, for purposes of service connection, at the time the claim was filed or during its pendency). The evidence weighing against the claim is the March 2011 VA examination report and September 2011 MEB report, to the extent it indicates bipolar disorder preexisted service. The March 2011 VA examiner's comments reflect uncertainty concerning the diagnosis. Although the examiner noted that the Veteran denied stress from military service, the May 2013 MHC report indicates that the Veteran has had continued psychiatric symptoms associated with PTSD. It is reasonable to infer that the continued psychiatric symptoms were triggered or started with military stressors. For these reasons, the Board does not consider the March 2011 VA medical opinion discounting the effect of military stressors to be probative evidence weighing against the claim. Then, the September 2011 MEB report is cursory and does not explain why the November 2006 PUHLES assessment indicating normal psychiatric fitness is inaccurate to find a preexisting disability. In sum, the Board does not consider either of these reports to be convincing evidence weighing against the claim. Based upon the above, the Board finds that service connection for an acquired psychiatric disorder, to include PTSD and bipolar disorder is warranted. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. The Board notes that the benefit granted herein is service connection for an acquired psychiatric disorder, to include PTSD and bipolar disorder. The issue on appeal was initially characterized as separate service connection issues for PTSD and bipolar disorder. Although the Federal Circuit has stated, "We recognize that bipolar disorder and PTSD could have different symptoms and it could therefore be improper in some circumstances for VA to treat these separately diagnosed conditions as producing only the same disability," Amberman v. Shinseki, 570 F.3d 1377, 1381 (Fed. Cir. 2009), that is not the situation here with regard to the Veteran's PTSD and bipolar disorder. See id. (considering the possibility that bipolar disorder and PTSD did not constitute the same disability, but rejecting this argument based on the facts of that case). Rather, the evidence above does not reflect that the Veteran's psychiatric symptoms can be separated or clearly attributed to one or another of his psychiatric disorders, and they must be considered as a single psychiatric disability. See Mittleider v. West, 11 Vet. App. 181, 182 (1998) (citing 61 Fed. Reg. 52698 (Oct. 8, 1996)) (when it is not possible to separate the effects of the service-connected and non-service-connected disabilities, the benefit of the doubt doctrine described in 38 C.F.R. § 3.102 dictates that such signs and symptoms be attributed to the service-connected disability or disabilities). The above evidence is sufficient to show that PTSD is related to fear of hostile military activity and bipolar disorder is related to service. B. Hypertension For VA compensation purposes, the term "hypertension" means that the diastolic blood pressure is predominantly 90 mm. or greater, or systolic blood pressure is predominantly 160 or more. 38 C.F.R. § 4.104, DC 7101 n.1 (2017). A diagnosis of hypertension "must be confirmed by readings two or more times on at least three different days." Id. The requirement of multiple blood pressure readings to be taken over multiple days as specified in Note (1) of DC 7101 applies to confirming the existence of hypertension. Gill v. Shinseki, 26 Vet. App. 386, 391 (2013). As noted above, STRs include two pre-deployment medical evaluations from November 2005 and March 2006. In both evaluations, the Veteran denied any significant medical history. Blood pressure readings from November 2006 and January 2006 were 139/82 and 137/82. On both evaluations, the examining clinicians rated the Veteran as "1" in every category on the PULHES profile report. The "PULHES" profile report is an acronym that represents the profile's six categories: "P" stands for "physical capacity or stamina"; "U" stands for "upper extremities"; "L" stands for "lower extremities"; "H" stands for "hearing and ear"; "E" stands for "eyes"; and "S" stands for "psychiatric." A profile serial is assigned on a scale of 1 to 4 for each of the six categories, with "1" indicating the highest level of fitness. See Odiorne, 3 Vet. App. at 457. As noted above, hypertension was not reported during service from the available STRs. February 2007 VA treatment records include blood pressure readings of 160/88 and 160/84 with an assessment of uncontrolled hypertension. March 2007 VA treatment records include a blood pressure reading of 114/64 and an assessment of likely essential hypertension. In May 2007, the Veteran was afforded a general medical examination. As relevant, the Veteran reported being initially diagnosed with hypertension when he returned from Iraq. He denied any symptoms or heart disease. However, the examiner noted two unexplained syncope episodes in Iraq. The examiner assessed the condition as improved with good response to medication. Three blood pressure readings were taken with normal findings. May 2009 National Guard records include blood pressure readings of 144/96 and 168/105. September 2010 VA treatment records include two separate blood pressure readings of 139/97 and 137/94 taken on the same day. May 2013 VA primary care records continue to list hypertension as a medical problem for the Veteran. The above evidence satisfies the three elements of service connection. The available STRs note elevated blood pressure readings for an in-service event and May 2013 VA treatment records indicate a current diagnosis for this claim. Then, for a nexus, continuity of symptomatology is shown. Within the first post-service year, two blood pressure readings indicate hypertension and a corresponding clinical assessment of hypertension is given. Additional blood pressure readings from May 2009 and September 2010 indicate continuing hypertension and satisfy the Gill, supra, measurements for hypertension diagnosis when considered with the February 2007 blood pressure readings. Entitlement to service connection for hypertension is therefore warranted. C. Tinnitus Service department records confirm that the Veteran served in Iraq in the vicinity of active combat. In-service noise exposure is conceded. In his November 2010 claim, the Veteran reported having bilateral tinnitus that started in July 2005 and was not treated. In February 2011, the Veteran had a VA audiology examination. He stated that he had noise exposure in Iraq from small arms fire, mortars and vehicles. Audiogram showed hearing within normal limits for each ear. The examiner expressed a negative medical opinion. She cited the Veteran's reports about an onset of intermittent tinnitus starting three to four months ago, approximately three and half years following service. In his October 2012, the Veteran clarified that he told the VA examiner his tinnitus was intermittent and had become much worse over the last three to four months. He attributed it to firing weapons during military service. In the statement accompanying his January 2014 substantive appeal, the Veteran explained that he had recurrent tinnitus since service. The VA examiner misunderstood him and stated that it was a recent onset. He had actually said that his tinnitus had become worse over the past three to four months. He reiterated that his tinnitus had started in service. Tinnitus is a highly symptom that the Veteran is competent to report. See Charles v. Principi, 16 Vet. App. 370, 374 (2002) ("ringing in the ears is capable of lay observation"). The Veteran's reports of tinnitus in and since service are competent, credible, and consistent with the circumstances of his service. See 38 U.S.C.A. § 1154(a); 38 C.F.R. § 3.303(a) (each disabling condition for which a veteran seeks service connection must be considered based on factors including the basis of places, types, and circumstances of service as shown by service record). Based on the above, the evidence is at least evenly balanced as to whether the Veteran has had tinnitus in and since service. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to service connection for tinnitus is warranted. 38 U.S.C. §5107(b); 38 C.F.R. §3.102. D. TBI As noted above, STRs from the Veteran's deployment are not available. The Veteran reported two syncope type episodes during his deployment that led him to have a medical evacuation. The etiology of the episodes was not determined. The May 2007 VA PTSD examination report includes subjective reports of memory loss. In October 2012, the Veteran acknowledged that he had not been formally tested, but believed he had TBI symptoms. He had been accidently struck in the head with a machine gun. He was wearing a helmet, but the impact was so strong that it cracked the helmet. Following the head strike, he had to sit down and rest. However, he was able to finish the mission. He later had an opportunity to seek medical attention, but declined since he felt better. He self-treated his residual headaches with Tylenol. Then, he had another instance of head trauma when he fell out of a chair head first onto the floor. Since he lost consciousness at this time and on a prior occasion, he was medically evacuated from Iraq. He was suspected to have seizures, but later medical evaluations ruled this diagnosis out. A medical explanation was not determined. He asserted that the loss of consciousness episodes were related to the above head trauma events. May 2013 VA TBI clinic records included reports of a blast injury and blunt trauma. The Veteran estimated that he was less than 10 feet from the blast. For the blunt trauma injury, he reported a brief period of disorientation and confusion. He endorsed several TBI type symptoms. The VA clinician reported that the history of injury and clinical symptoms were consistent with TBI. Based upon the above, the Board finds that service connection is warranted for TBI. The Veteran's reports of in-service head injuries from a blast exposure and blunt trauma are competent, credible, and consistent with the circumstances of his service. The May 2013 VA TBI clinic records confirm a current TBI type disability attributable to these in-service head injuries. As the three basic prongs of service connection are facially satisfied from the above clinical reports, service connection for TBI is granted. E. GERD, IBS, and non-typhoid salmonella The Veteran contends he incurred these disabilities in service. STRs from the Veteran's deployment are unavailable. However, his March 2011 reports concerning the salmonella outbreak and gastrointestinal symptoms occurring in service are competent and credible. January 2007 VA primary care (PC) records showed that the Veteran identified headaches, back pain and high blood pressure as symptoms lasting three months or longer or interfering with daily activities. March 2007 PC records listed current problems as adjustment disorder, hypertension, chronic rhinitis and low back pain. Clinical examination reflected that the Veteran appeared healthy. In March 2011, the Veteran was afforded a VA general medical examination. For IBS, he reported that it started in 2006 with recurrent diarrhea. Since his deployment, he had a soft stool once a day. He denied abdominal cramps, weight loss, fever and constipation. For GERD, he reported that the symptoms started in 2010 with a lot of food regurgitation and burning pain. He started medication with improved symptoms. He altered his diet and currently took Prilosec. For non-Typhoid salmonella, the Veteran reported his unit had a salmonella outbreak lasting three days. He had a mild case that resolved. During review of the symptoms, the Veteran endorsed having diarrhea, indigestion, hemorrhoids, and regurgitation. He had a history of melena that cleared with Prilosec. He had a recent gallbladder attack. He described having epigastric pain with certain foods and gallbladder pain. It was detailed as epigastric burning pain following consumption of certain foods. Prior to starting Prilosec, he had regurgitation. Clinical evaluation showed the Veteran to have a normal appearance. Abdomen inspection and bowel sounds were normal. No other abnormality or auscultation was found. Tenderness and guarding were not observed. A complete blood count (CBC) was taken. The examiner declined to diagnose IBS. She stated that the Veteran's symptoms did not meet the IBS diagnostic criteria. For GERD, she affirmed a current diagnosis and reported that it started four years following his deployment. For non-typhoid salmonella, the examiner concluded it had resolved and there was no evidence he had a current infection. The Veteran contends service connection is warranted for salmonella, IBS and GERD. The Board finds that the preponderance of the evidence is against these claims, even with heightened consideration of the benefit-of-the-doubt doctrine in instances where STRs are incomplete, as explained below. The symptoms associated with salmonella, IBS and GERD are readily observable. The Board has considered the Veteran's reported history and current symptoms for these disabilities. However, the pertinent issues for these claims are beyond the simple identification of injury and symptoms. For IBS and salmonellosis, a determination is needed as to whether the symptoms meet the clinical diagnostic parameters for IBS and for a residual disability from the in-service salmonella infection. For GERD, identification of a military nexus for post service symptom onset is needed. The Board deems these issues to be complex medical questions since they involve the clinical significance of the reported symptoms and a temporal lapse in GERD onset. Jandreau v. Nicholson, 492 F.3d 1372, 1376, n. 4 (Fed. Cir. 2007) ("sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer"). To the extent the lay reports assert current IBS, current salmonellosis, and a military nexus for post-service GERD, the Board does not find the lay reports competent evidence regarding these matters. 38 C.F.R. § 3.159(a)(1). For IBS and salmonellosis, the Board has reviewed the record with consideration as to whether such disability or residual disability is present. As a threshold issue, a current disability must be established for service connection. Degmetich v. Brown, 104 F. 3d 1328 (1997) (interpretation of 38 U.S.C. § 1110 and 38 U.S.C. § 1131 as requiring the existence of a present disorder for VA compensation purposes cannot be considered arbitrary and decision based on that interpretation must be affirmed); Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223 (1992); Rabideau v. Derwinski, 2 Vet. App. 141 (1992). The Board notes that a current disability encompasses any diagnosis given proximately to filing the claim and any diagnosis that appears during the claims period even if it later resolves. McClain v. Nicholson, 21 Vet. App. 319 (2007); see also Romanowsky v. Shinseki, 26 Vet. App. 303 (2013) (to the effect that where a disease or disability is diagnosed proximate to the current appeal period, but not currently, the Board is required to determine whether the earlier diagnosis was inaccurate or the previously diagnosed condition had gone into remission). For IBS and salmonellosis, the Board finds that a current disability is not shown at any time during the appeal period. Id. The VA treatment records do not reflect IBS, salmonellosis residuals or related diagnoses. The absence of reported symptoms corresponding to these disability weighs against the claim since it would reasonably be expected that significant gastrointestinal symptoms would be recorded in VA primary care records. See AZ v. Shinseki, 731 F.3d 1303, 1315-16 (Fed. Cir. 2013) (silence within records is pertinent evidence when records would typically document event in dispute); Buczynski v. Shinseki, 24 Vet. App. 221, 224 (2011) (silence in medical records may be relevant evidence that symptoms were not present if the record would normally have recorded such symptoms). The March 2011 VA examiner's determinations also weigh against these claims. The VA examiner explained that the Veteran's reported bowel symptoms did not meet the IBS diagnostic criteria and there was no recurrence of the salmonella infection. It is reasonable to infer from the VA examiner's comments that the in-service salmonellosis had fully resolved with no residual disability in light of the absence of reports in clinical records. Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012) (the fact that the rationale provided by an examiner "did not explicitly lay out the examiner's journey from the facts to a conclusion," did not render the examination inadequate). As these medical opinions are supported by a plausible rationale, they are therefore entitled to significant probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning; threshold considerations are whether the person opining is suitably qualified and sufficiently informed). Moreover, there is no contrary opinion in the evidence of record. As noted, the Veteran is not competent to opine on these questions of current disability for IBS or residual disability from in-service salmonellosis. Jandreau, 492 F.3d at 1376, n. 4. Briefly, the Board notes that a functional gastrointestinal disorder of altered bowel habits is a qualifying chronic disability under 38 C.F.R. § 3.317. However, the reported symptoms at the March 2011 VA examination were limited to stool consistency. They did not include abdominal cramps, weight loss, associated fever, nausea, vomiting, among others. The additional lay reports do not otherwise indicate that there were additional gastrointestinal symptoms that were not reported at the March 2011 VA examination. For these reasons, the evidence weighs against the presence of functional gastrointestinal disorder to warrant further consideration under 38 C.F.R. § 3.317 for the IBS claim. Regarding GERD, the Board finds that the evidence weighs against a nexus to service. VA treatment records from 2007 do not suggest the presence of any recurring gastroesophageal type symptoms. The evidence does not contain any suggestion that post-service GERD is otherwise related to active service. The Veteran's own report at the March 2011 VA examination dates the symptoms to 2010. The March 2011 VA examiner provided a negative medical opinion based upon the time lapse between service and symptom onset. Her explanation is plausible and consistent with the record. It is therefore entitled to significant probative weight. See Nieves-Rodriguez, 22 Vet. App. at 304. There is no contrary opinion in the evidence of record and as noted, the Veteran is not competent to opine on this question. Jandreau, 492 F.3d at 1376, n. 4. For the foregoing reasons, the preponderance of the evidence is against these claims. The benefit-of-the-doubt doctrine, even under heightened consideration where STRs are incomplete, is therefore not for application, and the claims for service connection for IBS, salmonellosis residuals and GERD, must be denied. ORDER The application to reopen the claim for service connection for PTSD is granted. The application to reopen the claim for service connection for bipolar disorder is granted. Service connection for an acquired psychiatric disability, to include PTSD and bipolar disorder, is granted. The application to reopen the claim for service connection for hypertension is granted. Service connection for hypertension is granted. Service connection for tinnitus is granted. Service connection for TBI is granted. Service connection for residuals of a salmonella infection, claimed as non-typhoid salmonella is denied. Service connection for IBS is denied. Service connection for GERD is denied. ______________________________________________ Jonathan Hager Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs