Citation Nr: 1805876 Decision Date: 01/30/18 Archive Date: 02/07/18 DOCKET NO. 13-22 067A ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Baltimore, Maryland THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disability, to include post-traumatic stress disorder (PTSD). 2. Entitlement to service connection for residuals of a traumatic brain injury. 3. Entitlement to service connection for a heart disability, claimed as due to exposure to herbicides. 4. Entitlement to service connection for a skin disability, claimed as due to exposure to herbicides. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD Mary C. Suffoletta, Counsel INTRODUCTION The Veteran served on active duty from September 1964 to September 1967, and had a prior period of active duty for training (ACDUTRA) from February 1964 to July 1964. These matters initially came to the Board of Veterans' Appeals (Board) on appeal from decisions of the RO in February 2011 and in February 2012 that, in pertinent part, denied service connection for a heart disability and for residuals of a traumatic brain injury; and declined to reopen claims for service connection for PTSD and for a skin disability on the basis that new and material evidence had not been received. The Veteran timely appealed. In March 2015, the Veteran withdrew his prior request for a Board hearing, in writing. In July 2015, the Board found new and material evidence to reopen the Veteran's claims; broadly construed and expanded the issue of service connection for PTSD on appeal as captioned above, in accordance with Clemons v. Shinseki, 23 Vet. App. 1 (2009); and remanded the case for additional development of the record. The Board is satisfied there was substantial compliance with its remand orders. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999); Stegall v. West, 11 Vet. App. 268, 271 (1998). FINDINGS OF FACT 1. The Veteran does not have a diagnosis of PTSD that conforms to regulatory requirements. 2. A currently diagnosed alcohol use in early remission or alcohol dependence was not manifested during active service and is not attributed to service. 3. The Veteran does not have current residuals of a traumatic brain injury that were present during active service, or related to a disease or injury during active service. 4. The Veteran's active service involved duty or visitation in the Republic of Vietnam during the Vietnam era; hence, he is presumed to have been exposed to Agent Orange in active service. 5. Ischemic heart disease with angina manifested to a compensable degree post-service. 6. Chloracne or other acneform disease consistent with chloracne did not manifest to a compensable degree within a year after the last date of the Veteran's exposure to the herbicide agent in Vietnam. 7. A skin disability is not show to be casually or etiologically related to any disease, injury, or incident in service; and is not otherwise related to service, to include exposure to herbicides. CONCLUSIONS OF LAW 1. An acquired psychiatric disability, to include PTSD, was not incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2017). 2. Residuals of traumatic brain injury were not incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2017). 3. Ischemic heart disease with angina is presumed to have been incurred in active service. 38 U.S.C. §§ 1110, 1112, 1113, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2017). 4. A skin disability was not incurred in active service, and chloracne or other acneform disease consistent with chloracne may not be presumed to have been incurred therein. 38 U.S.C. §§ 1110, 1112, 1113, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 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). These duties have been satisfied in this appeal. All available records identified by the Veteran as relating to his claim have been obtained, to the extent possible. Reports of VA examinations in connection with the claims on appeal are of record and appear adequate. The opinions expressed therein are predicated on a substantial review of the record and consideration of the Veteran's complaints and symptoms. The Veteran has not identified, and the record does not otherwise indicate, any existing pertinent evidence that has not been obtained. Given these facts, there is no further assistance that would be reasonably likely to assist the Veteran in substantiating the claims. 38 U.S.C. § 5103A(a)(2). II. Analysis Service connection is awarded for disability that is the result of a disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131. Service connection requires competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." 38 C.F.R. § 3.303(b). If a condition noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. Id. The Federal Circuit has held that section 3.303(b) applies only to those chronic conditions specifically listed in 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Notably, psychoses, brain hemorrhage, brain thrombosis, tumors of the brain, cardiovascular-renal disease, and scleroderma are considered chronic and presumptive diseases. See 38 U.S.C. § 1101. The Veteran is competent to testify on factual matters of which he has first-hand knowledge. Washington v. Nicholson, 19 Vet. App. 362 (2005). A. Acquired Psychiatric Disability The Veteran contends that an acquired psychiatric disability, to include PTSD, had its onset in active service. His personnel records reflect that he served in Vietnam from August 1965 to August 1966, and that his military occupational specialty was as a supply handler. Service treatment records show that the Veteran checked "no" in response to whether he ever had or now had nervous trouble of any sort or depression or excessive worry, on a "Report of Medical History" completed in August 1964 at entry. Clinical evaluation then revealed a normal psychiatric system. On a "Report of Medical History" completed in July 1967 at separation, it appears that the Veteran first checked "yes" and then his responses were corrected to reflect "no" in regard to frequent trouble sleeping, nervous trouble of any sort, and depression or excessive worry. Clinical evaluation at the time of the Veteran's separation examination in July 1967 showed a normal psychiatric system. VA records first show that the Veteran presented to the Emergency Room for psychiatric consultation in August 2002 due to marital conflict, and he reported being in an abusive relationship. He had no prior psychiatric history or psychiatric hospital admissions, and he did not meet inpatient admission criteria in August 2002; he then was referred for outpatient follow-up. Records, dated in August 2002, show complaints of chronic depression for several months and denial of suicidal ideation. Here, the Board finds that the evidence is against a finding that an acquired psychiatric disability was incurred in active service or within the first year after separation. In Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006), the Federal Circuit Court indicated that, where lay evidence provided is competent and credible, the absence of contemporaneous medical documentation during service or since, such as in treatment records, does not preclude further evaluation as to the etiology of the claimed disorder. And the Veteran, even as a layman, is competent to proclaim that he experienced depressive symptoms during active service. Here, the Veteran is competent to report what occurred in service because his statements regard his first-hand knowledge of a factual matter. However, competency is only one criterion. The lay evidence must also be credible. The Board finds that his statements are not credible with respect to onset or ongoing symptoms. Again, the Veteran checked "no" in response to whether he ever had or now had nervous trouble of any sort or depression or excessive worry on examination in 1967. Thus, it is not the absence of records, but rather the fact that the Veteran specifically denied such symptoms that the Board finds probative. With regard to PTSD, VA records show that a screening was negative for PTSD in July 2005. In June 2011, the Veteran reported that he feared for his life on numerous occasions in active service, especially when riding on an 18-truck convoy and receiving mortar rounds. Another stressor reported by the Veteran was that, on one occasion while he was in his pup tent, he was stomped on and beaten in 1966. The Veteran reportedly jumped out of the tent and fired his weapon; he thought that the unit had been overrun by the enemy, until he discovered that it was some fellow soldiers who had beat him. Initially, the Veteran was arrested and chained to a pole in the middle of a big tent, and charged with attempted murder. Charges were later dropped when the truth was discovered, and the Veteran returned to normal duties. In this case, the Board finds credible, competent and probative the Veteran's report of in-service stressors in Vietnam during active service. The in-service events are consistent with the places, types, and circumstances of the Veteran's service. The in-service stressors described by the Veteran involve his fear of hostile military or terrorist activity. Moreover, VA amended its regulations governing service connection for PTSD by liberalizing, in certain circumstances, the evidentiary standard for establishing in-service stressors. 75 Fed. Reg. 39843 (July 13, 2010). The primary effect of the amendment of 38 C.F.R. § 3.304(f) is the elimination of the requirement for corroborating evidence of a claimed in-service stressor, if it is related to the Veteran's fear of hostile military or terrorist activity. In place of corroborating any reported stressor, a medical opinion must instead be obtained from a VA, or a VA-contracted, psychiatrist or psychologist. In this regard, a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, must confirm that the claimed stressor is adequate to support a diagnosis of PTSD; and must confirm that the Veteran's symptoms are related to the claimed stressor. Here, the June 2012 examiner, who is a VA physician, found that the Veteran's in-service beating is adequate to support a diagnosis of PTSD. The stressor is related to the Veteran's fear of hostile military or terrorist activity; and his response involved intense fear, helplessness, or horror. The Board also notes behavioral changes reported by the Veteran when he went to Germany after Vietnam-such as having trouble thinking, getting along with others, and getting into fights. The Veteran reported being socially isolated at the time. The remaining evidence is against the Veteran's claim. The report of the June 2012 VA examination reflects that the Veteran's symptoms do not meet the diagnostic criteria for PTSD under the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (4th ed.) (1994) (DSM-IV) criteria. Rather, the June 2012 examiner diagnosed alcohol dependence; no other mental disorder was found. The Veteran described mild memory loss, and described a car accident in 1979 in which he hurt his head. He reported being under the influence of alcohol and marijuana at the time, and was prescribed antidepressants for over twenty years. He had no ongoing mental health treatment. He also reported being in the hospital for about one week after passing out during the day while trying to get out of his car. He reported that he drank the night before, and also drank some liquor and half a beer that morning. The Veteran reported getting multiple DUI's and moving violations, and that his license was last revoked in 2009. The Veteran reportedly stopped drinking and started going to church for about 12-to-15 years; and in the early-to-mid 1990's, he started drinking and using marijuana again. He reportedly has reduced his drinking to one or two drinks per day, since his last hospitalization. The June 2012 examiner indicated that the Veteran currently had impairment in social or occupational functioning due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, and that his symptoms were controllable by medication. Lastly, effective August 4, 2014, VA amended the portion of its Schedule for Rating Disabilities dealing with mental disorders and its adjudication regulations that define the term "psychosis" to remove outdated references to the Diagnostic and Statistical Manual of Mental Disorders (DSM) and replace them with references to the recently updated Fifth Edition (DSM-5). The provisions of the interim final rule apply to all applications for benefits that are received by VA or that were pending before the AOJ on or after August 4, 2014. Here, the RO certified the Veteran's appeal to the Board in November 2014 and, therefore, the claim is governed by DSM-5. Following the Board's July 2015 remand, the Veteran underwent a VA examination in August 2015 for purposes of determining the nature and etiology of his current psychiatric disability. The examiner reviewed the claims file (electronic) and noted the Veteran's medical history, and diagnosed "alcohol use disorder" in early remission. The Veteran had reported receiving prescribed medication for depressed mood in the past, and he reportedly went through a depression related to the death of his wife from cancer in 2009. He also had difficulty with alcohol and depression in 2011 and in 2013 due to financial issues. The Veteran reportedly had not been on medication in a couple of years because it made him drowsy. He also denied feeling depressed or anxious, and he believed that things were better now. The examiner, who is a VA physician, also opined that the Veteran did not display a pattern of behavior consistent with PTSD or with another mental health condition. Nor did he describe symptoms currently that met criteria for PTSD under DSM-5. In essence, the Veteran no longer thought about Vietnam "all that much anymore," and he had attended church about once a week for the past six months. He also slept about ten hours per night, and reduced his drinking of alcohol to only three-to-four drinks per month. In essence, the Veteran's PTSD symptoms have not caused impairment in social, occupational, or other important areas of functioning. The August 2015 examiner also opined that it is less likely as not that the Veteran's alcohol use in early remission was incurred or had its onset in active service. In support of the opinion, the August 2015 examiner reasoned that the Veteran had lifelong difficulty with alcohol and drug use; and that he had been drinking alcohol since age 16. The Veteran continued to drink alcohol in active service; and had periods of excessive drinking post-service due to the death of his wife in 2009, and legal issues with DUI's and financial difficulties in 2011 and 2013. The August 2015 examiner explained that the Veteran was prescribed medication to help with his mood in 2011 and in 2013; and explained that the Veteran was abusing alcohol at the time, which is a known depressant. In this regard, the Veteran cut back on his alcohol use and no longer took medication for depressive symptoms. The August 2015 examiner also opined that the Veteran currently did not meet clinical criteria for a depressive disorder. Nor does the evidence reflect ongoing treatment for any psychiatric disability. When assessing the probative value of a medical opinion, the thoroughness and detail of the opinion must be considered. The opinion is considered probative if it is definitive and supported by detailed rationale. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). A medical opinion that contains only data and conclusions is not entitled to any weight. "It is the factually accurate, fully articulated, sound reasoning for the conclusion, not the mere fact that the claims file was reviewed, that contributes probative value to a medical opinion." See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Board finds that the August 2015 examiner's opinions are entitled to greater probative weight than the Veteran's lay statements on the matter, as the August 2015 examiner reviewed the pertinent history to include the service treatment records and post-service treatment records, conducted a physical examination, and provided opinions with underlying reasons for the conclusions that are not contradicted by the record. As noted above, the Board finds credible, competent and probative the Veteran's reports of experiencing events during active service. However, the Board finds that the report of the August 2015 VA examination is more probative, given that it was conducted by a licensed psychologist, and provides a sound rationale for the finding that the Veteran's current alcohol use in early remission is not at least as likely as not related to events during active service. This is highly probative evidence against finding a nexus between any present psychiatric disability and active service. The Board finds the August 2015 examiner's opinions to be probative for resolving the matter on appeal. Here, the examiner has the medical knowledge to express a competent opinion; and found no evidence of any relationship between a current psychiatric disability and active service. The opinion appears accurate, and is fully articulated and contains sound reasoning. Lastly, there is some report of pre-service impairment due to alcohol use starting at age 16. However, there is no contemporaneous evidence of a pre-existing psychiatric disorder, no evidence of a psychiatric disorder at entrance, and no credible evidence of a psychiatric disorder during service or at separation. In fact, the Veteran repeatedly denied pertinent manifestations during the critical timeframe. Here, the presumption of soundness is not implicated. Gilbert v. Shenseki, 26 Vet. App. 48 (2012). In this case, the evidence weighs against a finding that a current psychiatric disability is linked to active service. The evidence is therefore against a finding that the Veteran's psychiatric disability either had its onset during active service or is related to the in-service events reported by the Veteran. The reasonable doubt doctrine is not for application. Thus, service connection for an acquired psychiatric disability, to include PTSD, is not warranted. See 38 U.S.C. § 5107(b) (2012). B. Residuals of a Traumatic Brain Injury The Veteran contends that he sustained a traumatic brain injury in 1966 when he was sleeping in his pup tent in Vietnam, and was stomped on by fellow soldiers-all over his head and body area-during active service. On a "Report of Medical History" completed by the Veteran at the time of separation from active service in July 1967, he checked "no" in response to whether he ever had or now had a history of head injury. Clinical evaluation in July 1967 revealed a normal head, face, neck, and scalp. VA records show treatment for possible stroke decades later in December 2009, and follow-up for an episode of Bell's palsy in January 2010. During a June 2012 VA examination, the Veteran also described a motor vehicle accident in 1979 in which his forehead went through a windshield and he hurt his head. He reported being unconscious at least until the next day because he woke up in the hospital. The Veteran reported being under the influence of alcohol and marijuana at the time, and he did not receive support from his supervisors for doctor visits for his head. He reportedly saw a psychiatrist due to problems with his memory and distractibility. The Veteran attributed his memory problems and distractibility both to the in-service physical assault and to the post-service motor vehicle accident in 1979. The June 2012 examiner opined that, based upon the Veteran's pattern of alcohol and drug use, it was not possible to determine the exact etiology of his memory problems or distractibility. The June 2012 examiner did not diagnose a traumatic brain injury. VA records show a history of syncope, and that the Veteran passed out in the kitchen in 2014. A computed tomography scan of the Veteran's brain in June 2014 revealed no acute intracranial abnormality. A remote infarct was noted within the deep white matter of the right frontal lobe. During an August 2015 VA examination, the Veteran reported being assaulted in his tent while sleeping in active service; and that he suffered a traumatic brain injury. He reported no physical injuries to head or loss of consciousness, but briefly dazed; and reported that he did not seek medical attention. He also reported being in the presence of nearby blasts in Vietnam, and being dazed briefly with no physical injuries or loss of consciousness. Following active service, the Veteran reported working fulltime for 30+ years as a custodian for a school system; and he retired in 2005. He reported noticing memory issues since 1979. The August 2015 examiner reviewed the Veteran's medical history, and noted that the Veteran reported "no" to head trauma, memory issues, or loss of consciousness in July 1967; and that he had a normal neurological examination at separation. Following examination in August 2015, the examiner did not diagnose a traumatic brain injury; and opined that the Veteran's traumatic brain injury is less likely as not related to active service. In support of the opinion, the August 2015 examiner reasoned that there is a lack of evidence to support that the Veteran suffered a traumatic brain injury in active service. In this case, the evidence reflects that the Veteran has not been diagnosed with any traumatic brain injury. He is not entitled to direct service connection for a traumatic brain injury because there is no competent evidence linking a current disability to any disease or injury in active service. The Board is within its province to make a determination as to whether the evidence supports a finding of service incurrence. See Barr, 21 Vet. App. at 307. The first requirement for any service connection claim is the existence of a current disability. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). In this regard, post-service records fail to reveal any diagnosis for the Veteran's allegations of a head injury due to stomping by fellow soldiers while the Veteran slept in his tent in 1966. Therefore, absent evidence of currently diagnosed residuals of traumatic brain injury, service connection cannot be granted. Id. The Board has considered the Veteran's statements regarding memory problems and distractibility as being among his current residuals of a traumatic brain injury. In this regard, no examiner has attributed any memory problems and distractibility to any in-service disease or injury. Moreover, the Veteran reported noticing memory problems following a 1979 motor vehicle accident where he suffered a head injury. Given the Veteran's pattern of alcohol use and drug use, the June 2012 examiner opined that it was not possible to determine the exact etiology of his memory problems or distractibility. No traumatic brain injury was found. The Board finds the conclusions of the June 2012 and August 2015 VA examiners, which are based on clinical evaluation and supported by rationale, to be more probative than references made by the Veteran. No medical examiner has made a formal diagnosis of any traumatic brain injury, concussion, or amnesia. Hence, a basis for compensation is not established. Because there is no evidence of current residuals of traumatic brain injury, the weight of the evidence is against the claim; and the doctrine of reasonable doubt is not applicable. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). C. Heart Disability The Veteran seeks service connection for a heart disability which he believes is due to exposure to herbicides in active service. VA laws and regulations provide that, if a Veteran was exposed to Agent Orange during service, certain listed diseases are presumptively service-connected if they manifest to a compensable degree at any time after service. 38 U.S.C. § 1116(a)(1); 38 C.F.R. § 3.307(a). Ischemic heart disease (including, but not limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal's angina) is listed among the diseases presumed to be associated with Agent Orange exposure. 38 U.S.C. § 1116(a)(2)(H); 38 C.F.R. § 3.309(e). A Veteran, who "served in the Republic of Vietnam" between January 9, 1962, and May 7, 1975, is presumed to have been exposed during such service to Agent Orange. 38 U.S.C. § 1116(f); 38 C.F.R. § 3.307(a)(6)(iii). Here, the Veteran's active duty included service in the Republic of Vietnam from August 1965 to August 1966; hence, he is presumed to have been exposed to herbicides in service. See 38 U.S.C. § 1116(f) (2012). The question in this case is whether the Veteran has developed a presumptive heart disability, which manifested to a compensable degree at any time after service. If so, service connection may be granted on the basis that certain disabilities are presumed to be the result of in-service Agent Orange exposure. The Veteran's enlistment examination in August 1964 showed a normal heart on clinical evaluation. Clinical evaluation at the time of the Veteran's separation from active service in July 1967 also showed a normal heart. The report of a September 1996 VA Agent Orange examination reveals no history of cardiovascular disease. Examination revealed that the heart was not enlarged, and tones were of good quality. There were no murmurs present, and peripheral pulses were adequate. VA records, dated in March 2004, show that the Veteran had no known history of coronary artery disease. At that time he reported having exertional dyspnea and chest tightness, most recently one month earlier. He also reportedly ran out of his blood pressure medications two-to-three days earlier. A Persantine stress test revealed mild chest heaviness after four minutes. An electrocardiogram in March 2004 revealed no abnormalities meeting criteria for ischemia. Private records, dated in September 2004, show a positive stress test typical of ischemia. At that time the Veteran had been involved in a motor vehicle accident and developed left chest pressure with radiation to his left axilla. Chest and rest tomographic images demonstrated normal myocardial perfusion. The Veteran exercised for five minutes and achieved a work level of 7 METs; testing was stopped due to fatigue, chest discomfort, and dyspnea. An electrocardiogram was negative for transient stress-induced myocardial ischemia at 83 percent of the maximal age-predicted heart rate. VA records show that the Veteran presented to the Emergency Department in June 2005 with complaints of heart racing for two-to-three days. He described this sensation as if his heart was beating out of his chest. He complained of chills, but denied fevers, cough, chest pain, and shortness of breath. The Veteran was admitted for chest pain, but had a negative stress test. A radiology report in March 2005 revealed no significant reversible ischemia provoked by Adenosine infusion. Examination of the Veteran's cardiovascular system in June 2005 revealed a regular, normal heart rate with neither murmurs nor rubs nor gallops. The Veteran was placed on a cardiac monitor. Electrocardiogram findings in June 2005 were more suggestive of ischemia than of hypokalemia. An echocardiogram in July 2005 was normal. VA records show that the Veteran presented to the Emergency Department in December 2009, stating that he thought he had a stroke one week earlier. He reportedly was out-of-town and noncompliant with his blood pressure medications. Examination of the Veteran's cardiovascular system in December 2009 revealed a regular, normal heart rate with neither murmurs nor rubs nor gallops. The report of a July 2010 VA examination reveals a diagnosis of a normal heart examination. The examiner reviewed the Veteran's medical history, and noted some complaints of dizziness; the Veteran had been on multiple medications for hypertension in the last five years. He had no complaint of dyspnea or syncope. A stress test revealed that the Veteran had some chest pain without changes of myocardial ischemia in the electrocardiogram. He had no history of myocardial infarction, heart failure, rheumatic heart disease, thyroid heart disease, endocarditis, pericarditis, or pericardial effusions. A stress test was negative for ischemic heart disease, and a MUGA study revealed normal heart chambers and normal ejection fraction of 55 percent to 60 percent. Estimated clinical METs level was 10. Examination in July 2010 revealed no evidence of heart failure like rales, edema, or liver enlargement. In January 2014, the Veteran reported symptoms of angina. A carotid Doppler in May 2014 revealed no evidence of clinically significant carotid artery stenosis, bilaterally. An echocardiogram in June 2014 revealed normal left ventricular size and systolic function, and abnormal left ventricular filling pattern. A VA physician at the time suspected that the Veteran may have had arrhythmia from very low potassium. The report of an August 2015 VA examination reveals that the Veteran had not been diagnosed with any heart disability. The examiner reviewed the Veteran's medical history and diagnostic testing results from May 2014, which revealed evidence of neither cardiac hypertrophy nor cardiac dilatation; a normal electrocardiogram; a normal chest X-ray; and a normal echocardiogram. Here, the Board finds that the medical evidence is conflicting as to the presence of a current disability. Both the July 2010 and August 2015 examiners have opined that the Veteran does not have any heart disability. The August 2015 examiner based the opinion on diagnostic testing results from May 2014. To the contrary, however, other diagnostic testing was suggestive of ischemia. The Board also notes current evidence of angina in 2014; and recognizes the Court's decision in Romanowsky v. Shinseki, 26 Vet. App. 303 (2013), which held that a claimant satisfies the current disability threshold when a disability exists at the time his or her claim was filed, even if the disability resolves prior to VA's adjudication of the claim. Moreover, the Board finds the Veteran's statements credible and supported by medical evidence showing ongoing complaints of heart racing, angina, and arrhythmia. Lastly, the diseases listed at 38 C.F.R. § 3.309(e) generally shall have become manifest to a degree of 10 percent or more disabling at any time after service, unless otherwise noted. The diagnostic criteria applicable to evaluating diseases of the heart are found in 38 C.F.R. § 4.104. Several diagnostic codes relate to the cardiovascular system; in this regard, primarily, a 10 percent rating is warranted for diseases of the heart where, (1) stress test results demonstrate, generally, a workload of greater than 7 METs (metabolic equivalents) but not greater than 10 METs resulting in dyspnea, fatigue, angina, dizziness or syncope, or; (2) when continuous medication is required. For all diseases of the heart, the rating criteria provide that one MET is the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 millimeters per kilogram of body weight per minute. 38 C.F.R. § 4.104, Note (2). In this case, the evidence includes findings of angina since 2014; and an exercise test was conducted in September 2004, where a METs level of 7 was indicated. In this regard, the testing was stopped due to fatigue and chest discomfort and dyspnea. The Board also notes a report of no significant reversible ischemia, rather than no disease, with another report of positive stress test typical of ischemia. The Board is unable to find that the physicians who noted ischemia are less competent than the examiners who found no disease. At best, the evidence is in equipoise. Accordingly, the Board finds that the Veteran has developed a presumptive heart disability, which manifested to a compensable degree after service. Hence, service connection is warranted for ischemic heart disease with angina. In reaching this decision, the Board has extended the benefit of the doubt to the Veteran. 38 U.S.C. § 5107. D. Skin Disability The Veteran seeks service connection for a skin disability which he believes is due to exposure to herbicides in active service. VA laws and regulations provide that, if a Veteran was exposed to Agent Orange during service, chloracne or other acneform disease consistent with chloracne are presumptively service-connected if they manifest to a compensable degree within a year after the last date of such exposure to the herbicide agent in active service. 38 U.S.C. § 1116(a)(1); 38 C.F.R. § 3.307(a). As noted above, the Veteran is presumed to have been exposed to herbicides in service. See 38 U.S.C. § 1116(f) (2012). The Veteran's enlistment examination in August 1964 showed normal skin on clinical evaluation. Records show treatment for a rash on one occasion in March 1966. Clinical evaluation at the time of the Veteran's separation from active service in July 1967 showed normal skin. In August 1996, the Veteran reporting receiving medications from VA for a skin rash for several years. He reported that his skin rash became "hard to handle" and that he had pigmentations all over his shoulders and back. The report of a September 1996 VA skin examination reveals a past medical history of folliculitis of the scalp over the past eight years, previously treated with tetracycline orally with good response. The Veteran currently was with inactive disease and off tetracycline for one year. He also reported an eight-year history of acne vulgaris, which last exacerbated four months ago. He noted a two-month history of multiple hypopigmented areas on the upper arms, and stated that all his relatives have a similar rash. Following examination in 1996, the examiner diagnosed acne vulgaris, mild; folliculitis of the scalp, resolved at present; and post-inflammatory hypopigmentation of the shoulders and upper back. The examiner opined that the most likely etiology of the post-inflammatory hypopigmentation, given the configuration, was tinea versicolor-although a definitive diagnosis could not be made due to the absence of organisms; and that resolved rashes leading to secondary hypopigmentation were possible, including possible early vitiligo. In this case, the evidence reflects that chloracne or other acneform disease consistent with chloracne did not to manifest to a compensable degree within a year after the last date of the Veteran's exposure to the herbicide agent in Vietnam. Thus, notwithstanding the fact that the Veteran served in Vietnam during the Vietnam era and is presumed to have had Agent Orange exposure, service connection on a presumptive basis as due to Agent Orange exposure is not warranted for any claimed skin disability. The Board notes, however, that the Federal Circuit has held that a claimant is not precluded from establishing service connection for a disease averred to be related to herbicide exposure, as long as there is proof of such direct causation. See Combee v. Brown, 34 F.3d 1039, 1043-1044 (Fed. Cir. 1994). See also Brock v. Brown, 10 Vet. App. 155, 160-61 (1997), vacated on other grounds (Fed. Cir. 2000). Post-service records first show treatment for folliculitis, for acne, and for tinea pedis in 1988-i.e., many years after the Veteran's separation from active service. He also was treated for a rash on the back and chest post-service in 1989, in 1990, in 1991, in 1993, and in 1995. In September 2003, the Veteran reported that his skin continued to break out in a rash over his shoulder and back. No chronic disability listed in 38 C.F.R. § 3.309(a), such as scleroderma, has been diagnosed; hence, reports of continuity of symptomatology do not assist the Veteran in this case. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2012). The report of an August 2015 VA skin examination includes a diagnosis of tinea versicolor. The examiner reviewed the Veteran's medical history, and noted that the Veteran currently was not on medication for any skin disability. Following examination in August 2015, the examiner opined that it is less likely than not that the Veteran's tinea versicolor is related to the rash that he was treated for in 1966. In support of the opinion, the examiner reasoned that there was no mention of a rash or of any skin disease at the time of the Veteran's separation examination. The examiner indicated that, as a medical provider, she could not determine whether this Veteran's diagnosis of tinea versicolor was related to herbicide exposure. As such, there is no opinion linking tinea versicolor to herbicide exposure. Significantly, in this case, the evidence is against a finding that any skin disability was present during active service or within the first post-service year, or is otherwise related to disease or injury in active service-including exposure to herbicides. Clearly, the Veteran did not have characteristic manifestations sufficient to identify a skin disability in active service; the one incident of a rash was deemed acute, resolved prior to separation from service, and was not identified as chloracne or other acneform disease consistent with chloracne. The Veteran's current skin disabilities were diagnosed long after service, with no competent opinion linking them to disease or injury in active service. While the Veteran is competent to report symptoms of a skin rash, he is not competent to provide an etiology opinion linking current tinea versicolor to active service, as this is beyond the capacity of a lay person to observe. Moreover, even if he were competent to render a diagnosis and opinion, his opinion is outweighed by the August 2015 examiner's opinion that current tinea versicolor is not related to disease or injury in active service. There was no finding of any skin disability at the time of the Veteran's separation from active service, or within a year of his last exposure to herbicides in Vietnam. The August 2015 examiner's opinion is entitled to greater probative weight as the examiner reviewed the history, conducted a physical examination, and provided an opinion that is supported by a rationale and by service treatment records. The Board is within its province to make a determination as to whether the evidence supports a finding of service incurrence. See Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). As indicated above, the first credible showing of pertinent disability is many years after active service with no competent evidence that a skin disability is in any way related to active service. In short, for the reasons and bases stated above, the Board concludes that the evidence weighs against granting service connection for a skin disability. On this matter, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. at 53-56. ORDER Service connection for an acquired psychiatric disability, to include PTSD, is denied. Service connection for residuals of a traumatic brain injury is denied. Service connection for ischemic heart disease with angina is granted. Service connection for a skin disability is denied. ____________________________________________ H. N. SCHWARTZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs