Citation Nr: 18141888 Decision Date: 10/12/18 Archive Date: 10/11/18 DOCKET NO. 16-14 940 DATE: October 12, 2018 ORDER New and material evidence having not been received, the claim for service connection for hypertension is not reopened. New and material evidence having not been received, the claim for service connection for erectile dysfunction is not reopened. New and material evidence having not been received, the claim for service connection for sleep apnea is not reopened. Entitlement to service connection for a prostate condition is denied. Entitlement to service connection for posttraumatic stress disorder (PTSD) is granted. Entitlement to service connection for headaches is granted. Entitlement to service connection for shortness of breath is denied. FINDINGS OF FACT 1. In a final decision decided in November 2013, the RO denied the Veteran’s claim of entitlement to service connection for hypertension. 2. The evidence received since the November 2013 RO denial does not relate to an unestablished fact necessary to substantiate the claim of service connection for hypertension. 3. In a final decision decided in November 2013, the RO denied the Veteran’s claim of entitlement to service connection for erectile dysfunction. 4. The evidence received since the November 2013 RO denial does not relate to an unestablished fact necessary to substantiate the claim of service connection for erectile dysfunction. 5. In a final decision decided in November 2013, the RO denied the Veteran’s claim of entitlement to service connection for sleep apnea. 6. The evidence received since the November 2013 RO denial does not relate to an unestablished fact necessary to substantiate the claim of service connection for sleep apnea. 7. As the Veteran served in Vietnam during the Vietnam War era, he is presumed to have been exposed to herbicide agents, to include Agent Orange, during such service. 8. The Veteran does not have, and at no point pertinent to the current claim on appeal has had, prostate cancer, the only prostate-related disease among those recognized by the VA Secretary as etiologically related to herbicides exposure. 9. No prostate disability was shown in service or for many years thereafter, and there is no competent, probative evidence or opinion even suggesting that there exists a medical relationship between the Veteran’s prostate condition and the Veteran’s military service. 10. The evidence of record is in relative equipoise as to whether the Veteran currently has PTSD that is at least as likely as not etiologically related to service. 11. Resolving reasonable doubt in the Veteran’s favor, the Veteran’s current headaches began in service. 12. The evidence of record does not clearly and unmistakably show that the Veteran had a respiratory disorder, characterized by shortness of breath prior to entry to active duty; therefore, he is presumed sound upon entry into service as to a neck disability. 13. A respiratory disorder manifested by shortness of breath is not shown to be causally or etiologically related to any disease, injury, or incident in service, and did not manifest within one year of the Veteran’s separation from service. CONCLUSIONS OF LAW 1. The April 2010 RO decision, which denied service connection for hypertension is final. 38 U.S.C. § 7105 (b) (West 2014); 38 C.F.R. § 20.1100 (2017). 2. Evidence received since the April 2010 rating decision is not new and material, and the claim of service connection for hypertension is not reopened. 38 U.S.C. § 5108 (West 2014); 38 C.F.R. § 3.156 (2017). 3. The April 2010 RO decision, which denied service connection for erectile dysfunction is final. 38 U.S.C. § 7105 (b) (West 2014); 38 C.F.R. § 20.1100 (2017). 4. Evidence received since the April 2010 rating decision is not new and material, and the claim of service connection for erectile dysfunction is not reopened. 38 U.S.C. § 5108 (West 2014); 38 C.F.R. § 3.156 (2017). 5. The April 2010 RO decision, which denied service connection for sleep apnea is final. 38 U.S.C. § 7105 (b) (West 2014); 38 C.F.R. § 20.1100 (2017). 6. Evidence received since the April 2010 rating decision is not new and material, and the claim of service connection for sleep apnea is not reopened. 38 U.S.C. § 5108 (West 2014); 38 C.F.R. § 3.156 (2017). 7. The criteria for service connection for a prostate condition, to include as due to exposure to herbicides are not met. 38 U.S.C. §§ 1101, 1110, 1112, 1137, 5103, 5103A, 5107 (West 2014); 3.102, 3.159, 3.303, 3.304, 3.307, 3.309 (2017). 8. Resolving reasonable doubt in the Veteran’s favor, the criteria are met to establish service connection for PTSD. 38 U.S.C. §§ 1110, 1131, 5107(b) (2014); 38 C.F.R. §§ 3.102, 3.303, 3.304(f) (2017). 9. The criteria for service connection for headaches have been met. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.303, 3.304, 3.310, 3.317 (2017). 10. The criteria for establishing entitlement to service connection for a disorder manifested by shortness of breath have not been met. 38 U.S.C. §§ 1110, 1131, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 1967 to February 1969. These matters come before the Board of Veterans’ Appeals (Board) on appeal from rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO). Regarding the Veteran’s claim for PTSD, the claim was initially denied in an April 2010 rating decision. The Veteran filed a notice of disagreement (NOD) in August 2014. A statement of the case (SOC) was issued in March 2016, and the Veteran perfected his appeal, via a VA Form 9, in March 2016. Regarding the Veteran’s claims for hypertension, erectile dysfunction, and sleep apnea, each were denied in an April 2010 rating decision. The Veteran filed an NOD in December 2014. An SOC was issued in October 2016, and the Veteran perfected his appeal, via a VA Form 9, in October 2016. Regarding the Veteran’s claims for a prostate disorder, headaches, and shortness of breath, a rating decision was issued in October 2014. The Veteran filed an NOD in December 2014. An SOC was issued in October 2016, and the Veteran perfected his appeal, via a VA Form 9, in October 2016. Hypertension, erectile dysfunction, sleep apnea, and PTSD, were each denied in an April 2010 rating decision. An SOC was issued in March 2016 for the PTSD claim and another SOC was issued in October 2016 as to the remaining claims. New and Material Claims Generally, if a claim for service connection has been previously denied and that decision became final, the claim can be reopened and reconsidered only if new and material evidence is presented with respect to that claim. 38 U.S.C. § 5108 (West 2014). “New” evidence is defined as 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 previously of record, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156 (a). The Court interpreted the language of 38 C.F.R. § 3.156 (a) as creating a low threshold, and viewed the phrase “raises a reasonable possibility of substantiating the claim” as “enabling rather than precluding reopening.” Shade v. Shinseki, 24 Vet. App. 110 (2010). For the purpose of establishing whether new and material evidence has been received, the credibility of the evidence, but not its weight, is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). Despite determinations reached by the RO, the Board must find new and material evidence in order to establish its jurisdiction to review the merits of a previously denied claim. See Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996); Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001). PTSD In an April 2010 rating decision, the RO denied the claim for PTSD because although a diagnosis of PTSD was noted in the Veteran’s medical records, it did not meet all the diagnostic criteria as stated in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) published by the American Psychiatric Association. Additionally, the Veteran’s stressor was unable to be corroborated. At the time of the April 2010 decision, the evidence of record included service treatment records (STRs), VA and private treatment records, the Veteran’s statements, and a memorandum regarding a lack of information required to corroborate stressors. The Veteran was informed of the April 2010 decision and of his appellate rights, but he did not appeal that decision or submit new and material evidence within one year following notification of that decision. Accordingly, the April 2010 decision became final. 38 U.S.C. § 7105 (West 2014); 38 C.F.R. §§ 3.156 (b); 20.302, 20.1103 (2017); see also Bond v. Shinseki, 659 F.3d 1362 (Fed. Cir. 2011); see also Buie v. Shinseki, 24 Vet. App. 242, 251-52 (2010). The evidence received since the April 2010 RO decision includes a private DBQ and medical opinion. This evidence relates to an unestablished fact needed to establish service connection (i.e., a currently diagnosed psychiatric disability). Therefore, the Board finds that new and material evidence has been received and the criteria to reopen the Veteran’s claim for entitlement to service connection for PTSD are met. Hypertension The Veteran seeks service connection for hypertension. In an April 2010 decision, the RO denied the claim for hypertension on a presumptive and direct basis since hypertension is not recognized as a disease associated with herbicide agent exposure, did not manifest during service, and did not manifest to a compensable degree within one year of discharge. At the time of the April 2010 decision, the evidence of record included STRs which were silent for a finding of hypertension, private and VA treatment records, and the Veteran’s statements. In a private treatment record, a physician noted that the Veteran was treated for elevated blood pressure readings and outpatient VA treatment reports revealed a diagnosis of hypertension dating back to March 2009. The Veteran was informed of the April 2010 decision and of his appellate rights, but he did not appeal that decision or submit new and material evidence within one year following notification of that decision. Accordingly, the April 2010 decision became final. 38 U.S.C. § 7105 (West 2014); 38 C.F.R. §§ 3.156 (b); 20.302, 20.1103 (2017); see Bond, supra; see also Buie, supra. The evidence received since the April 2010 RO decision includes additional VA treatment records reflecting continued treatment for hypertension. While the treatment records received since April 2010 are new, they are not material to the claim for service connection for hypertension. Again, at the time of the April 2010 rating decision, the evidentiary record failed to document a nexus between the Veteran’s diagnosed hypertension and service. Similarly, none of the newly submitted evidence, demonstrates or otherwise identifies a nexus between the Veteran’s hypertension and service. Since the Veteran has not provided new and material evidence in this regard, the claim for service connection for hypertension cannot be reopened at this time. The Board acknowledges the Veteran’s assertions that his hypertension is a result of service. Lay persons are competent to provide opinions on some medical issues. Although the Veteran is competent to report symptoms and experiences observable by his senses, the specific issue in this case (i.e., whether his hypertension is a result of service) falls outside the realm of common knowledge of the Veteran. Compare Jandreau v. Nicholson, 492 F .3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay witness capable of diagnosing dislocated shoulder); see also Barr v. Nicholson, 21 Vet. App. 303, 308-9 (2007); Falzone v. Brown, 8 Vet. App. 398, 403 (1995) (lay person competent to testify to pain and visible flatness of his feet); with Clemons v. Shinseki, 23 Vet. App. 1, 6 (2009) (“It is generally the province of medical professionals to diagnose or label a mental condition, not the claimant”); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (unlike varicose veins or a dislocated shoulder, rheumatic fever is not a condition capable of lay diagnosis); Jandreau, 492 F.3d at 1377, n.4 (“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”). See also Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed. Cir.2010) (recognizing that in some cases lay testimony “falls short” in proving an issue that requires expert medical knowledge). In this case, determining the nature and etiology of any hypertension requires specialized knowledge which is not within the competence of the Veteran or his attorney in this case, who has not been shown by the evidence of record to have medical training or skills. Thus, to the extent that the Veteran is attempting to determine the etiology of his hypertension, his lay statements in this regard are not considered competent evidence. Without competent evidence of the etiology of his hypertension, none of the newly-received evidence addresses any fact left unestablished at the time of the April 2010 decision or raises a reasonable possibility of substantiating the Veteran’s claim, and therefore, it is not new and material for purposes of reopening the claim. Accordingly, the Board finds that the record contains no new and material evidence sufficient to reopen the claim for hypertension. As such, the claim is not reopened. In the absence of new and material evidence, the benefit-of-the-doubt rule does not apply, and the petition to reopen the claim must be denied. See Annoni v. Brown, 5 Vet. App. 463, 467 (1993).   Erectile dysfunction The Veteran seeks service connection for erectile dysfunction. In an April 2010 decision, the RO denied the claim for erectile dysfunction on a presumptive and direct basis since erectile dysfunction is not recognized as a disease associated with herbicide agent exposure, did not manifest during service, and did not manifest to a compensable degree within one year of discharge. At the time of the April 2010 decision, the evidence of record included STRs which were silent for a finding of erectile dysfunction, private and VA treatment records, and the Veteran’s statements. The Veteran’s outpatient treatment records documented a diagnosis of impotence and the Veteran’s private physician noted that he had suffered from erectile dysfunction for the last eight years. The Veteran was informed of the April 2010 decision and of his appellate rights, but he did not appeal that decision or submit new and material evidence within one year following notification of that decision. Accordingly, the April 2010 decision became final. 38 U.S.C. § 7105 (West 2014); 38 C.F.R. §§ 3.156 (b); 20.302, 20.1103 (2017); see Bond, supra; see also Buie, supra. The evidence received since the April 2010 RO decision includes additional VA treatment records reflecting continued treatment for erectile dysfunction. While the treatment records received since April 2010 are new, they are not material to the claim for service connection for erectile dysfunction. Again, at the time of the April 2010 rating decision, the evidentiary record failed to document a nexus between the Veteran’s diagnosed erectile dysfunction and service. Similarly, none of the newly submitted evidence, demonstrates or otherwise identifies a nexus between the Veteran’s erectile dysfunction and service. Since the Veteran has not provided new and material evidence in this regard, the claim for service connection for erectile dysfunction cannot be reopened at this time. The Board acknowledges the Veteran’s assertions that his erectile dysfunction is a result of service. Lay persons are competent to provide opinions on some medical issues. Although the Veteran is competent to report symptoms and experiences observable by his senses, the specific issue in this case (i.e., whether his erectile dysfunction is a result of service) falls outside the realm of common knowledge of the Veteran. Compare Jandreau v. Nicholson, 492 F .3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay witness capable of diagnosing dislocated shoulder); see also Barr v. Nicholson, 21 Vet. App. 303, 308-9 (2007); Falzone v. Brown, 8 Vet. App. 398, 403 (1995) (lay person competent to testify to pain and visible flatness of his feet); with Clemons v. Shinseki, 23 Vet. App. 1, 6 (2009) (“It is generally the province of medical professionals to diagnose or label a mental condition, not the claimant”); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (unlike varicose veins or a dislocated shoulder, rheumatic fever is not a condition capable of lay diagnosis); Jandreau, 492 F.3d at 1377, n.4 (“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”). See also Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed. Cir.2010) (recognizing that in some cases lay testimony “falls short” in proving an issue that requires expert medical knowledge). In this case, determining the nature and etiology of any erectile dysfunction requires specialized knowledge which is not within the competence of the Veteran or his attorney in this case, who has not been shown by the evidence of record to have medical training or skills. Thus, to the extent that the Veteran is attempting to determine the etiology of his erectile dysfunction, his lay statements in this regard are not considered competent evidence. Without competent evidence of the etiology of his erectile dysfunction, none of the newly-received evidence addresses any fact left unestablished at the time of the April 2010 decision or raises a reasonable possibility of substantiating the Veteran’s claim, and therefore, it is not new and material for purposes of reopening the claim. Accordingly, the Board finds that the record contains no new and material evidence sufficient to reopen the claim for erectile dysfunction. As such, the claim is not reopened. In the absence of new and material evidence, the benefit-of-the-doubt rule does not apply, and the petition to reopen the claim must be denied. See Annoni v. Brown, 5 Vet. App. 463, 467 (1993). Sleep apnea The Veteran seeks service connection for sleep apnea. In an April 2010 decision, the RO denied the claim for sleep apnea as there was no diagnosis provided. At the time of the April 2010 decision, the evidence of record included STRs which were silent for a finding of sleep apnea, private and VA treatment records, and the Veteran’s statements. The Veteran’s outpatient treatment records showed that the Veteran described symptoms of snoring and fatigue, but no diagnosis of sleep apnea was provided. The Veteran was informed of the April 2010 decision and of his appellate rights, but he did not appeal that decision or submit new and material evidence within one year following notification of that decision. Accordingly, the April 2010 decision became final. 38 U.S.C. § 7105 (West 2014); 38 C.F.R. §§ 3.156 (b); 20.302, 20.1103 (2017); see Bond, supra; see also Buie, supra. The evidence received since the April 2010 RO decision includes additional VA treatment records which reflect an absence of apnea, snoring, and insomnia. While the treatment records received since April 2010 are new, they are not material to the claim for service connection for sleep apnea. Again, at the time of the April 2010 rating decision, the evidentiary record failed to document a diagnosis of sleep apnea, as well as a nexus to service. Similarly, none of the newly submitted evidence, demonstrates or otherwise identifies a diagnosis or nexus. Since the Veteran has not provided new and material evidence in this regard, the claim for service connection for sleep apnea cannot be reopened at this time. The Board acknowledges the Veteran’s assertions that his sleep apnea is a result of service. Lay persons are competent to provide opinions on some medical issues. Although the Veteran is competent to report symptoms and experiences observable by his senses, the specific issue in this case (i.e., whether his erectile dysfunction is a result of service) falls outside the realm of common knowledge of the Veteran. Compare Jandreau v. Nicholson, 492 F .3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay witness capable of diagnosing dislocated shoulder); see also Barr v. Nicholson, 21 Vet. App. 303, 308-9 (2007); Falzone v. Brown, 8 Vet. App. 398, 403 (1995) (lay person competent to testify to pain and visible flatness of his feet); with Clemons v. Shinseki, 23 Vet. App. 1, 6 (2009) (“It is generally the province of medical professionals to diagnose or label a mental condition, not the claimant”); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (unlike varicose veins or a dislocated shoulder, rheumatic fever is not a condition capable of lay diagnosis); Jandreau, 492 F.3d at 1377, n.4 (“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”). See also Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed. Cir.2010) (recognizing that in some cases lay testimony “falls short” in proving an issue that requires expert medical knowledge). Without competent evidence of a diagnosis or symptoms that functionally impair the Veteran to constitute a disability, none of the newly-received evidence addresses any fact left unestablished at the time of the April 2010 decision or raises a reasonable possibility of substantiating the Veteran’s claim, and therefore, it is not new and material for purposes of reopening the claim. Accordingly, the Board finds that the record contains no new and material evidence sufficient to reopen the claim for sleep apnea. As such, the claim is not reopened. In the absence of new and material evidence, the benefit-of-the-doubt rule does not apply, and the petition to reopen the claim must be denied. See Annoni v. Brown, 5 Vet. App. 463, 467 (1993). Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may be granted for any disease diagnosed after discharge from service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). In order to establish service connection on a direct basis, there must be competent evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). See also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The determination as to whether elements are met is based on an analysis of all the evidence of record and the evaluation of its competency, credibility and probative value. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Baldwin v. West, 13 Vet. App. 1, 8 (1999). Certain chronic diseases, such as a malignant tumor, may be presumed to have been incurred in service if manifest to a compensable degree within one year from discharge from service, provided further that the rebuttable presumption provisions of 38 C.F.R. § 3.307 are also satisfied. 38 U.S.C. §§ 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). With chronic disease shown as such in service (or within the presumptive period under § 3.307) so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributed to intercurrent causes. For the showing of chronic disease, there are required a combination of manifestations sufficient to identify a 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). Continuity of symptomatology is required only where the condition noted during service is not, in fact, shown to be chronic or when the diagnosis of chronicity may be legitimately questioned. Id. Notably, the continuity and chronicity provisions of 38 C.F.R. § 3.303 (b) only apply to the chronic diseases enumerated in 38 C.F.R. § 3.309 (a). Absent affirmative evidence to the contrary, there is a presumption of exposure to herbicides (to include Agent Orange) for all Veterans who served in Vietnam during the Vietnam Era (the period beginning on January 9, 1962, and ending on May 7, 1975). 38 U.S.C. § 1116 (f) and 38 C.F.R. § 3.307 (a)(6). Furthermore, if a Veteran was exposed to an herbicide agent (to include Agent Orange) during active military, naval, or air service, certain diseases, including prostate cancer, shall be service-connected if the requirements of 38 C.F.R. § 3.307 (a)(6) are met, even if there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 C.F.R. § 3.307 (d) are also satisfied. 38 C.F.R. § 3.309 (e). Thus, a presumption of service connection arises for these Veterans (presumed exposed to Agent Orange) or, alternatively, a Veteran without appropriate service (as described above) but with competent evidence of herbicide exposure, who develops one of the identified diseases. VA has determined that there is no positive association between exposure to herbicides and any other condition for which it has not specifically been determined that a presumption of service connection is warranted. See Notice, 59 Fed. Reg. 341-346 (1994); see also 61 Fed. Reg. 57586 - 57589 (1996). In adjudicating a claim for VA benefits, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). 1. Entitlement to service connection for a prostate condition, to include as secondary to exposure to an herbicide agent. The Veteran has asserted that his claimed prostate disability is due to Agent Orange exposure during his service in the Republic of Vietnam. The Veteran’s personnel records document service in Vietnam in 1968. Thus, the Veteran is presumed to have been exposed to herbicides, to include Agent Orange. See 38 C.F.R. § 3.307 (a)(6)(iii). However, prostate cancer is the only enumerated disability, relating to the prostate, that is presumed due to herbicide exposure that are listed under 38 C.F.R. § 3.309 (e). Although prostate cancer is one of the enumerated disabilities presumed due to herbicide exposure, there is no prostate cancer diagnosis of record. Accordingly, establishing service connection on a presumptive basis as due to Agent Orange is not available to the Veteran as there is no evidence of record that the Veteran has prostate cancer. Notwithstanding the presumption, the Veteran may still establish service connection for his prostate condition due to herbicide exposure with proof of direct causation, or on any other recognized basis. See Brock v. Brown, 10 Vet. App. 155, 162-64 (1997); Combee v. Brown, 34 F. 3d 1039, 1044 (Fed. Cir. 1994), citing 38 U.S.C. § 1113 (b) and 1116 and 38 C.F.R. § 3.303. However, after a full review of the record, including the medical evidence and statements made by the Veteran, the Board finds that the most persuasive medical evidence and opinions of record do not support a finding that (1) the Veteran has or has ever had prostate cancer; or (2) there exists a medical relationship between the Veteran’s diagnosed prostate condition and any presumed herbicide exposure in service, or other incident therein. The Veteran’s service treatment records (STRs) are unremarkable for any complaints, findings, or diagnoses of a prostate condition or of any precursor during service. The only urological issue noted in service was urethritis acute due to gonococci that was treated in July 1968; no other followup or complications regarding the infection were noted. The Veteran’s first recorded problem with his prostate came over four decades after service in June 2010, at which time he was diagnosed with BPH. His symptoms included the inability to empty his bladder and dribbling. VA treatment records, dated in June 2010, September 2011, October 2012, December 2013, March 2016, reveal that the Veteran’s prostate cancer screenings were negative. He was also deemed a low prostate cancer risk due to negative family history and negative prostate-specific antigen (PSA) findings. The Board has considered the Veteran’s statements that his current prostate disorder is related to service, to include his exposure to Agent Orange. Again, the Board notes that presumptive service connection is not warranted because the Veteran does not have and has never been diagnosed with prostate cancer. Instead, he has been diagnosed with BPH (an enlarged prostate) and his biopsies and screenings for prostate cancer have been negative. As to direct service connection, the Veteran has not asserted that any physician has told him his prostate disorder is related to service. Furthermore, the Veteran, as a lay person, has not been shown to be capable of providing an opinion, especially as to the complex medical opinion such as the etiology or diagnosis of any current prostate disorder, which is quite different from statements regarding the presence of scars or varicose veins which are capable of lay observation. See Charles v. Principi, 16 Vet. App. 370, 374-75 (2002). Given the Veteran’s lack of demonstrated medical expertise, no probative weight is afforded to his statements as to the etiology of his condition. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (explaining that a Veteran is competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions); see also Layno v. Brown, 6 Vet. App. 465 (1994) (cautioning that lay testimony that the Veteran suffered a particular illness (bronchial asthma) was not competent evidence because matter required medical expertise). There is also no assertion by the Veteran that he had had BPH continuously since active service; in fact, the first documented evidence that the Veteran had any diagnosable prostate issues came in 2010, over four decades after discharge from active service. An examination is not warranted for the claim of entitlement to service connection for a prostate condition, as there is no competent lay or medical evidence to suggest that any such condition began during, or was the result of, active duty service. Again, the only suggested relationship between the claimed disorder and active duty service comes from the Veteran himself. To the extent of his contentions of the existence of a nexus, his lay statements relating his disability to active service are not competent, and no medical evidence has been submitted to support such a proposition. The Court has held that, in circumstances similar to this, where the supporting evidence of record consists only of a lay statement, VA is not obligated, pursuant to 5103A(d), to provide an appellant with a medical nexus opinion. See Duenas v. Principi, 18 Vet. App. 512, 519 (2004). In summary, there is no competent evidence of record that has linked the Veteran’s prostate disorder to service, to include exposure to Agent Orange. Therefore, the claim for service connection for a prostate disorder is denied. In arriving at the decision to deny this claim, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the most persuasive, competent evidence weighs against the claim, that doctrine is not applicable. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). 2. Entitlement to service connection for PTSD The Veteran contends that service connection is warranted for an acquired psychiatric disorder, to include PTSD. Service connection for PTSD requires medical evidence establishing a diagnosis of the condition, credible supporting evidence that the claimed in-service stressor actually occurred, and a link, established by medical evidence, between the current symptomatology and the claimed in-service stressor. 38 C.F.R. § 3.304 (f) (2017). Within the legal framework for evaluating claims of service connection for PTSD, the sufficiency of a stressor is a medical determination, while the occurrence of the stressor is a legal determination. Sizemore v. Principi, 18 Vet. App. 264 (2004). Of record is an October 2012 treatment note which indicates a diagnosis of PTSD. A November 2012 letter from a psychiatrist at a VA hospital, Dr. M.G., also indicates that a diagnosis of PTSD. The Veteran was then afforded a VA Initial PTSD examination in October 2013. The VA examiner stated that the Veteran did not have a diagnosis of PTSD. See October 2013 VA examination report. Specifically, the examiner noted the Veteran did not meet Criterion D-F and noted that “although the claimant reports some symptoms consistent with PTSD, his symptoms do not meet the criteria for a DSM diagnosis.” The Veteran submitted a November 2014 statement from his sister, M.P., which indicated that prior to service, the Veteran was happy, outgoing, sociable, and active in sports and hobbies. Yet, when he returned from Vietnam, he was unhappy, withdrawn, emotional, depressed, argumentative, hypervigilant, and suffered from sleep impairments and an exaggerated startle response. The Veteran also submitted a private DBQ from a licensed psychologist, Dr. H.H. in January 2015. Upon examination, the psychologist determined that the Veteran met criterion A-E of the PTSD diagnostic criteria which established a diagnosis of PTSD. The psychologist also noted that the Veteran had a depressed mood, anxiety, suspiciousness, near-continuous panic or depression, chronic sleep impairment, mild memory loss, impairment of memory, flattened affect, impaired abstract thinking, disturbances of motivation and mood, difficulty adapting to stressful circumstances, the inability to establish and maintain effective relationships, persistent delusions or hallucinations, persistent danger of hurting self or others, neglect of personal appearances and hygiene, and intermittent ability to perform activities of daily living. Further, the psychologist opined that the Veteran’s troubling PTSD symptoms were more likely than not caused by service. See January 2015 medical opinion. Here, the Board finds the evidence is in equipoise as to whether or not there is a current diagnosis of PTSD. Therefore, giving the Veteran the benefit of the doubt, the Board finds a current diagnosis of PTSD. As to the in-service stressor element, at his October 2013 VA examination, the Veteran told the psychologist about his traumatic experiences in Vietnam. The Veteran described witnessing the killing of a serviceperson that he was in charge of as well as standing in between M16s during an argument of his fellow servicepersons. See October 2013 VA examination report. The examiner noted that the first stressor identified met Criterion A. Importantly, the October 2013 VA examiner noted that one of the Veteran’s alleged stressors met Criterion A and related to the Veteran’s fear of hostile military or terrorist activity. Without clear and convincing evidence to the contrary, lay testimony, alone, may be sufficient to establish the occurrence an in-service stressor related to fear of hostile military activity. See 38 C.F.R. § 3.304 (f)(3). Here, the Veteran’s lay statements are sufficient to establish his in-service stressor as the record does not contain any clear and convincing evidence to the contrary. As the evidence for and the evidence against the Veteran’s claim is in relative equipoise, the Board affords the Veteran the benefit of the doubt, and finds there is expert evidence of record establishing a link between the Veteran’s PTSD and his in-service stressor. Accordingly, the Board grants service connection for PTSD. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. 3. Entitlement to service connection for headaches The Veteran contends that service connection is warranted for headaches. In an October 1969 separation examination, the Veteran complained of frequent or severe headaches. The Veteran submitted a private DBQ in April 2017, at which time the Veteran was diagnosed with headaches. The Veteran reported that his headaches began in service and that his headaches have increased in frequency and severity over the years. The Veteran further reported that he experienced headache pain, to include constant head pain, pulsating or throbbing head pain, pain localized to one side of the head, pain on both sides of the head, and pain which worsened with physical activity. Additionally, the examiner noted that the Veteran’s headaches lasted less than a day and were not prostrating in nature. The examiner further noted that it was at least as likely as not that the Veteran’s headaches were caused by service or, alternatively, by his service-connected PTSD and tinnitus. The rationale provided was that medical evidence supports a link between psychological stress and headaches and that tinnitus is linked to the frequency of headaches. Given that the Veteran complained of headaches in service, he currently has headaches, and there is a medical opinion relating his headaches to service and to his service-connected disabilities of PTSD and tinnitus, the Board will resolve reasonable doubt in the Veteran’s favor and finds that service connection for headaches is warranted. 4. Entitlement to service connection for a respiratory disorder, characterized by shortness of breath The Veteran contends that service connection is warranted for a respiratory disorder, characterized by shortness of breath. At the outset, the Board notes that the Veteran stated that he had asthma upon entry, but denied shortness of breath. The examination report also includes a notation of bronchial asthma. Nevertheless, the examination report shows a normal clinical evaluation of the lungs and chest. Upon separation, the Veteran denied asthma and shortness of breath. The Veteran’s service treatment records are silent as to complaints, diagnosis, or treatment for shortness of breath. As such, the Board finds that there is not clear and unmistakable evidence of a pre-existing respiratory condition, characterized by shortness of breath. The report of physical and examination at induction was negative for any disabilities or defects regarding shortness of breath, and the Veteran’s report of asthma at the time of examination does not constitute a notation of such conditions. 38 C.F.R. § 3.304 (b)(1). As there is no other evidence of record supporting any pre-service respiratory disorder, characterized by shortness of breath, the Board finds that the presumption of soundness at service entrance with respect to shortness of breath has not been rebutted. Therefore, this is a case of direct service connection rather than one of aggravation by service. See Wagner, 370 F.3d at 1096. The Board notes that no examination has been provided regarding the Veteran’s claimed respiratory disorder. In determining whether the duty to assist requires that a VA medical examination be provided or medical opinion obtained with respect to a Veteran’s claim for benefits, there are four factors for consideration. These four factors are: (1) whether there is competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) whether there is evidence establishing that an event, injury, or disease occurred in service, or evidence establishing certain diseases manifesting during an applicable presumption period; (3) whether there is an indication that the disability or symptoms may be associated with the veteran's service or with another service-connected disability; and (4) whether there otherwise is sufficient competent medical evidence of record to make a decision on the claim. 38 U.S.C. 5103A (d); 38 C.F.R. § 3.159 (c)(4). The threshold for determining a possibility of a nexus to service is a low one, but it is a threshold nonetheless. McLendon v. Nicholson, 20 Vet. App. 79 (2006). Here, there is no indication of a respiratory condition in service, and no evidence of signs or symptoms of a respiratory disability to trigger the duty to examine. Therefore, the Board finds that a VA examination is not warranted regarding the claim for a respiratory disability claimed as shortness of breath. Turning to the theory of direct service connection, the Board determines that service connection is not warranted for a respiratory disorder, characterized by shortness of breath. First, the Veteran’s service treatment records do not reflect complaints of, treatment for, or a diagnosis related to a respiratory disorder. Significantly, the Veteran’s separation physical examination fails to document any complaints or observed symptoms related to a respiratory disorder. Similarly, the Veteran’s post-service evidence does not reflect symptoms related to a respiratory disorder, characterized by shortness of breath. Specifically, a September 2011 podiatry consultation report indicates that the Veteran did not have a pulmonary condition, to include shortness of breath. The Veteran’s treatment records reveal that he also denied shortness of breath in October 2010, January 2011, September 2011, October 2012, and July 2013. Further, a December 2013 primary care treatment note reveals that the Veteran denied chest discomfort, pain, and pressure as well as shortness of breath. Service connection may also be granted when the evidence establishes a medical nexus between active duty service and current complaints. In this case, the Board finds that the weight of the competent evidence does not attribute the Veteran’s claimed disorder to active duty, despite his contentions to the contrary. The evidence of record does not indicate a relationship between any respiratory disorder and active duty service, nor has any treating physician opined that any of these disorders is related to active duty. The Board recognizes that the Veteran believes that he currently suffers from a respiratory disorder, characterized by shortness of breath that is related to an event that occurred during military service. However, he has provided VA with no evidence that indicates a specific in-service injury, event, or disease that may have caused his shortness of breath. To the extent that the Veteran advances his own interpretation of his medical condition indicating that his respiratory disorder is related to service, the Board acknowledges that lay witnesses may, in some circumstances, opine on questions of diagnosis and etiology. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (Board’s categorical statement that a “valid medical opinion” was required to establish nexus, and that a layperson was “not competent” to provide testimony as to nexus because she was a layperson, conflicts with Jandreau). In any event, the probative value of the Veteran’s general assertions and observations is outweighed by the probative value of the evidence which documents the fact that the Veteran has not presented any evidence showing an in-service event that would have caused his respiratory disorder. Further, because this disorder is not diagnosed by unique and readily identifiable features, it does not involve a simple identification that a layperson is competent to make. The unsubstantiated statements regarding the claimed etiology of the Veteran’s claimed respiratory disorder, characterized by shortness of breath is found to lack competency. Aside from his lay statements, the Veteran has not provided any evidence or explanation to offer a medical opinion as complex as linking his respiratory disorder to his military service over 40 years ago. As such, based on the foregoing, service connection cannot be established, as there is no competent or credible evidence indicating a positive link between the Veteran’s claimed respiratory disorder, characterized by shortness of breath and any event in service. For the foregoing reasons, the preponderance of the evidence is against the claim. The benefit-of the-doubt doctrine is therefore not for application, and the Veteran’s claim of entitlement to service connection for a respiratory disorder, characterized by shortness of breath must be denied. See 38. U.S.C. § 5107(b); 38 C.F.R. § 3.102; Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009). L. M. BARNARD Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Tiffany N. Hanson, Associate Counsel