Citation Nr: 1822014 Decision Date: 04/13/18 Archive Date: 04/25/18 DOCKET NO. 14-30 784 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to service connection for a right ankle disability. 2. Entitlement to service connection for swollen joints and arthritis of the knees, left ankle, hips, shoulders, and elbows. 3. Entitlement to service connection for a respiratory disability manifested by shortness of breath. 4. Entitlement to service connection for a heart disability manifested by palpitations. 5. Entitlement to service connection for alopecia areata. ORDER Service connection for a right ankle disability is granted. Service connection for swollen joints and arthritis of the knees, left ankle, hips, shoulders, and elbows is denied. Service connection for a respiratory disability manifested by shortness of breath is denied. Service connection for a heart disability manifested by palpitations is denied. The appeal regarding entitlement to service connection for alopecia areata is dismissed. FINDINGS OF FACT 1. The Veteran's current right ankle disability is etiologically related to his active service. 2. The evidence does not demonstrate a current disability of the knees, left ankle, hips, shoulders, or elbows, or a current respiratory disability. 3. Symptoms of a heart disability were not continuous or recurrent in service or since service separation, and there is no medical nexus between the current heart disability and active service. 4. On March 10, 2017, prior to the promulgation of a decision in the appeal, the Veteran requested a withdrawal of his appeal regarding entitlement to service connection for alopecia areata. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in favor of the Veteran, the criteria for service connection for a right ankle disability have been met. 38 U.S.C. §§ 101, 1101, 1110, 1131, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2017). 2. The criteria for service connection for swollen joints and arthritis of the knees, left ankle, hips, shoulders, and elbows are not met. 38 U.S.C. §§ 101, 1101, 1110, 1131, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2017). 3. The criteria for service connection for a respiratory disability are not met. 38 U.S.C. §§ 101, 1101, 1110, 1131, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2017). 4. The criteria for service connection for a heart disability manifested by palpitations are not met. 38 U.S.C. §§ 101, 1101, 1110, 1131, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2017). 5. The criteria for withdrawal of an appeal by the Veteran have been met with regard to the issue of entitlement to service connection for alopecia areata. 38 U.S.C. § 7105(b)(2), (d)(5) (2012); 38 C.F.R. § 20.204 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran, who is the Appellant in this case, had active service from August 1973 to August 1976. This matter comes before the Board of Veterans' Appeals (BVA or Board) from a July 2012 rating decision by the above Department of Veterans Affairs (VA) Regional Office (RO). The Veteran and his wife provided testimony at a March 2017 videoconference hearing before the undersigned Veterans Law Judge at the VA office in San Antonio. A transcript of the hearing is associated with the claims folder. The issues certified to the Board included entitlement to service connection for swollen joints and arthritis of the knees, ankles, hips, shoulders, and elbows. However, because service connection for a right ankle disability is granted herein, the Board has separated the issue of entitlement to service connection for a right ankle disability from the issue of service connection for the remaining joints, as characterized on the title page of this decision. The Board also notes that the RO denied service connection for a right ankle disability in a December 2008 rating decision, and that the December 2008 rating decision became final. See 38 U.S.C. § 7105; 38 C.F.R. §§ 20.302, 20.1103. Thus, the Veteran should have been advised that new and material evidence was required to reopen the right ankle disability claim he filed in May 2010. However, the Board finds that new and material evidence necessary to reopen the claim has been received, and a detailed discussion of reopening of the claim is unnecessary. Service Connection Laws and Regulations Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires (1) competent evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) competent evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The United States Court of Appeals for Veterans Claims (Court) has held that "Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability there can be no valid claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). Where a veteran who served for ninety days or more during a period of war (or during peacetime service after December 31, 1946) develops certain chronic diseases, such as arthritis, to a degree of 10 percent or more within one year from separation from service, such diseases may be presumed to have been incurred in service even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. See 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Where the veteran asserts entitlement to service connection for a chronic disease but there is insufficient evidence of a diagnosis in service, service connection may be established under 38 C.F.R. § 3.303(b) by demonstrating a continuity of symptomatology since service or diagnosis within the presumptive period after service, but only if the chronic disease is listed under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331, 1338-39 (Fed. Cir. 2013); 38 C.F.R. § 3.307 (service connection authorized for chronic diseases diagnosed within the presumptive period). With specific regard to continuity of symptomatology, 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. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. If a condition, such as arthritis, noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b). In this case, as discussed below, the evidence does not demonstrate current arthritis of the knees, left ankle, hips, shoulders, or elbows. The remaining conditions at issue are not any of the "chronic diseases" listed under 38 C.F.R. § 3.309(a); therefore, 38 C.F.R. § 3.309(b) (requiring continuity of a condition after service if chronicity is not found in service) does not apply to those disorders. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In addition, service connection can be presumed if a veteran was exposed to an herbicide agent during active service. 38 C.F.R. § 3.309(e). Presumptive service connection for the listed disabilities as a result of Agent Orange exposure is warranted if the requirements of 38 C.F.R. § 3.307(a)(6) are met. 38 U.S.C. § 1116; 38 C.F.R. § 3.309(e). The governing law provides that a "veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, shall be presumed to have been exposed during such service to an herbicide agent . . . unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service." 38 U.S.C. § 1116(f). In this case, there is no indication or contention that the Veteran served in Vietnam. Rather, he avers that he was exposed to Agent Orange at Fort Polk, as discussed below. Moreover, the Veteran has not been diagnosed with any of the diseases presumptively related to herbicide exposure in 38 C.F.R. § 3.309(e). However, if there is no presumptive service connection available, direct service connection can be established if the record contains competent medical evidence of a current disease process with a relationship to exposure to an herbicide agent while in military service. See 38 U.S.C. § 1110; 38 C.F.R. § 3.303; Combee v. Brown, 34 F.3d 1039, 1043-44 (Fed. Cir. 1994). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). Lay testimony is competent when it regards the readily observable features or symptoms of injury or illness and "may provide sufficient support for a claim of service connection." See Layno, 6 Vet. App. At 469; 38 C.F.R. § 3.159(a)(2). The Court has emphasized that when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. In such cases, the Board is within its province to weigh that testimony and to make a credibility determination as to whether that evidence supports a finding of service incurrence and continuity of symptomatology sufficient to establish service connection. See Barr v. Nicholson, 21 Vet. App. 303 (2007); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept. 14, 2009). Lay statements may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of a veteran's claims file. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005) (rejecting medical opinions that did not indicate whether the physicians actually examined the veteran, did not provide the extent of any examination, and did not provide any supporting clinical data). The Court has held that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). A significant factor to be considered for any opinion is the accuracy of the factual predicate, regardless of whether the information supporting the opinion is obtained by review of medical records or lay reports of injury, symptoms and/or treatment. See Harris v. West, 203 F.3d 1347, 1350-51 (Fed. Cir. 2000) (examiner opinion based on accurate lay history deemed competent medical evidence in support of the claim); Kowalski v. Nicholson, 19 Vet. App. 171, 177 (2005) (holding that a medical opinion cannot be disregarded solely on the rationale that the medical opinion was based on history given by the veteran); Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that the Board may reject a medical opinion based on an inaccurate factual basis). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. The Board has reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by a veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Service Connection for Right Ankle Disability The Veteran claims that his current right ankle disability was caused by a right ankle injury during active service. His service treatment records show that in October 1974, he fell into a ditch while walking and twisted his right ankle. He was diagnosed with a severe right ankle sprain and placed in a cast. X-ray studies were negative for fracture. In November 1984, approximately three weeks after the injury, his cast was removed and it was noted that he had essentially full range of motion without swelling. Whirlpool treatment was recommended. His April 1976 separation examination report indicates normal clinical evaluation of the lower extremities. However, a separate consultation note indicates that the Veteran complained of pain in his right ankle during cold, damp weather and with running since he sprained the ankle in 1974. Clinical evaluation of the ankle was normal as were repeat x-ray studies. The clinician assessed probable minimal degenerative joint disease in the right ankle. The Veteran was afforded a VA examination in November 2008. The VA examiner reviewed the above history of the right ankle injury in service. On examination, there were no constitutional symptoms of arthritis, and current x-ray studies were negative. The VA examiner noted a normal right ankle examination with a stable joint, and opined that there was no right ankle condition that could be related to service, as there was no evidence to substantiate continued disability post-service, and no evidence of treatment post-service. The RO, in its December 2008 rating decision, denied the claim for a right ankle disability, finding no evidence of a current disability. In July 2015, VA treatment records show that the Veteran reported right ankle pain localized at a bone protrusion at the lateral aspect of the talo-metatarsal junction. He stated that the bony protrusion had been there since active service, but that it had grown larger over time. The clinician diagnosed a bony protrusion/exostosis to the right foot at the cuboid/calcaneous joint with pain on palpation. Surgical intervention was discussed. It was noted that previous x-ray studies of the right ankle showed an old fracture of lateral calcaneous area/old sequelae of prior trauma. In March 2016, a private physician, Dr. A., wrote a letter stating that he focuses on disorders of the spine and had been treating the Veteran for chronic pain syndrome due to chronic foot and ankle pain stemming from a severe injury sustained while in the military. The doctor opined that it is more likely than not that his injuries during military service were the source of his chronic pain syndrome and dysfunction, including the current ankle disability. There are no other medical nexus opinions of record. After a review of all of the evidence of record, lay and medical, the Board finds that the evidence is at least in equipoise as to whether the Veteran's current right ankle disability is related to his active service. As such, the benefit-of-the-doubt will be conferred in the Veteran's favor and his claim for service connection for a right ankle disability is granted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Service Connection for Swollen Joints and Arthritis of the Knees, Left Ankle, Hips, Shoulders, and Elbows, and a Respiratory Disability Next, the Veteran contends that he has swollen joints and arthritis of the knees, left ankle, hips, shoulders, and elbows, and a respiratory disability manifested by shortness of breath that are related to his active service. At the March 2017 Board hearing, he testified that he injured his elbows when he twisted his right ankle in service. He has not provided specific contentions with regard to the remaining joints. He has stated that his shortness of breath is due to Agent Orange exposure during active service. After a review of all of the evidence of record, lay and medical, the Board finds that the weight of the evidence demonstrates that the Veteran does not have a current disability of the knees, left ankle, hips, shoulders, or elbows, or a respiratory disability. Service treatment records are negative for any signs, reports, complaints, symptoms, findings, treatment, or diagnoses of disabilities of the knees, left ankle, hips, shoulders, or elbows, or a respiratory disability. The Veteran checked "yes" next to "swollen or painful joints" and "shortness of breath" on his Report of Medical History at the April 1976 separation examination, and the examining clinician noted shortness of breath on exertion. However, the separation examination report indicates a normal clinical evaluation of the lungs and upper and lower extremities. In addition, a chest x-ray was negative, and while consultations were ordered for heart palpitations and right ankle problems, there was no notation of any disability of the knees, left ankle, hips, shoulders, elbows, or respiratory system. Following service separation, in June 2009, the Veteran sought treatment for back pain since a 2007 work injury, but denied shortness of breath, and there were no joint pains on examination. An October 2009 VA treatment note indicates no respiratory complaints, and no musculoskeletal complaints other than chronic back problems from the work injury in 2007. Lungs were clear to auscultation and no respiratory distress was noted. There was no edema in the extremities. In December 2009, the Veteran denied any respiratory problems and respiratory examination was noted to be negative. In March 2010, lungs were clear to auscultation and the Veteran denied shortness of breath. A chest x-ray was normal with no evidence of acute cardiopulmonary disease. In April 2010, the Veteran reported dyspnea at rest with heart palpitations. It was noted that he had smoked a half a pack of cigarettes per day for 40 years. Physical examination of the lungs was within normal limits, as was musculoskeletal examination. In a September 2010 statement, the Veteran stated that he sought treatment in 1985 for swollen legs. After a blood test, he stated he was told that he had arthritis in his ankle and knees and was prescribed medication. However, these records are not available as the physician passed away. In November 2010, the respiratory system was noted to be normal. Lungs were clear to auscultation and no distress was noted. He was diagnosed with seasonal allergies and given a prescription for Flunisolide spray. Musculoskeletal examination revealed no edema, including of the extremities. In May 2011, the Veteran told his VA treating clinician that he had arthritis in his joints, presenting "VA disability papers" documenting such, and requested a refill of Vicodin prescribed by his private physician. The VA clinician noted that the extremities had good range of motion with no joint swelling. However, he noted arthritis per patient record. A September 2011 treatment note indicates good range of motion of joints and no leg edema, as well as no shortness of breath. A chest x-ray was taken in May 2012 as part of a VA heart examination, with notation of a history of shortness of breath. The x-ray study showed clear lungs with no acute airspace disease. In June 2012, the Veteran presented with neck pain radiating to his elbows bilaterally, with symptoms present for several years. An EMG study revealed evidence of cervical nerve root irritation syndrome, and an MRI of the cervical spine was recommended. A November 2012 treatment note indicates muscle strength of 5 out of 5 in the lower extremities with no joint crepitus present. There was adequate range of motion of the ankle joints, subtalar joints, Lisfranc joint, metatarsal phalangeal joints, and interphalangeal joints bilaterally. In sum, the overwhelming preponderance of the evidence demonstrates no current disability of the knees, left ankle, hips, shoulders, or elbows, or a respiratory disability. This is because the evidence fails to show that there are underlying maladies related to a service incurred injury or disease responsible for the vaguely described symptoms. Indeed, as noted above, it appears that the Veteran's elbow pain has been attributed to a non-service-connected cervical spine disability. In addition, in the March 2016 letter referenced above, Dr. A. related neck and back problems to active service, but did not mention the knees, hips, shoulders, or elbows. Finally, at the Board hearing, the Veteran indicated that his shortness of breath was associated with sleep apnea; this is a separate disorder for which service connection was denied in a June 2017 rating decision. Regarding the Veteran's statements that he has current disabilities of the knees, left ankle, hips, shoulders, and elbows, and a respiratory disability, the Board recognizes that lay witnesses may, in some circumstances, opine on questions of diagnosis and etiology. See Davidson, 581 F.3d at 1316 (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, 492 F.3d 1372). However, while the Veteran is competent to provide his lay description of symptoms, such as pain and shortness of breath, he is not competent to determine whether these symptoms constitute a residual disability of an event that occurred during active service. Such a diagnosis and finding of medical etiology requires specific medical knowledge and training. See Rucker, 10 Vet. App. at 74 (stating that a lay person is not competent to diagnose or make a competent nexus opinion about a disorder as complex as cancer). Without a showing of a current disability, the claim for service connection must be denied. "Congress specifically limits entitlement to service-connected disease or injury where such cases have resulted in a disability . . . in the absence of a proof of present disability there can be no claim." Brammer, 3 Vet. App. at 225. The Board recognizes that the Court has held that the presence of a chronic disability at any time during the claim process can justify a grant of service connection, even where the most recent diagnosis is negative. McClain v. Nicholson, 21 Vet. App. 319 (2007). However, where the overall record fails to support a current disability, as is the case here, that holding would not apply. Because a current disability has not been shown by competent evidence, the Board does not reach the additional question of the relationship between the claimed disabilities and active service. Therefore, the Board finds that a preponderance of the lay and medical evidence that is of record weighs against the claims for service connection for disabilities of the knees, left ankle, hips, shoulders, and elbows, and a respiratory disability, and the claims must be denied. Because the preponderance of the evidence is against the claims, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Service Connection for Heart Disability Finally, the Veteran contends that when he was in basic training, they were out in the field one day and were told to get in a fox hole, and that a helicopter passed by them and sprayed "orange smoke" which he believes was Agent Orange. He believes that exposure to Agent Orange caused his heart palpitations. However, the Board finds that the weight of the evidence is against a grant of service connection for a heart disability. Service treatment records show that at the April 1976 separation examination, the Veteran reported several episodes of heart palpitations while at rest that lasted for a few seconds and were relieved by sitting down and holding his breath. Objective examination of the heart was negative and an EKG was normal. The consulting physician diagnosed possible paroxysmal atrial tachycardia, but noted that there was no objective evidence of this diagnosis. The Veteran was deemed fit for separation and no physical profile was needed. The first post-service documented report of heart palpitations was in March 2010, when the Veteran presented to the emergency department reporting palpitations on and off within the prior few weeks, becoming increasingly persistent, and chest pain. Telemetry revealed sinus bradycardia. He was diagnosed with supraventricular tachycardia, status post conversion with adenosine, and substernal chest pain. An April 2010 private treatment record indicates that his risk factors for heart disease included hypertension and dyslipidemia. The physician recommended an exercise tolerance test and echocardiogram. The exercise tolerance test revealed normal left ventricular function, no evidence of stress-induced left ventricular dilatation, no evidence of reversible ischemia, and a normal myocardial perfusion study. The echocardiogram also demonstrated normal left ventricular systolic function. The Veteran was afforded a VA examination in May 2012. The examiner noted a diagnosis of supraventricular arrhythmia in 2010, and diagnosed cardiac dysrhythmias based on a current EKG, which showed arrhythmia described as sinus bradycardia. A chest x-ray and echocardiogram were normal. An interview-based METS test revealed dyspnea, fatigue, angina, dizziness, and syncope at greater than 7 to 10 METs. After reviewing the claims file and noting the in-service history of palpitations as well as current palpitations, the VA examiner stated that his current heart conditions (chest pain and palpitations) are caused by hypertension, for which he takes medication, noting that hypertension is a risk factor for the development of cardiac dysrhythmias. The examiner stated that the origin of the Veteran's palpitations while in military service were unknown, noting that his blood pressure readings were within normal limits during military service, and that no physiological abnormalities or cardiac conditions were noted during active service. The examiner further stated that palpitations can also stem from psychological conditions, like stress or anxiety. In sum, due to the absence of hypertension during active service, the examiner stated that it is less likely as not that the Veteran's current cardiac dysrhythmias are related to the symptoms seen and treated in military service. More current private and VA treatment records show ongoing treatment for and monitoring of tachycardia/arrhythmias. After a review of all the evidence of record - lay and medical - in conjunction with the applicable laws and regulations - the Board finds that the preponderance of the evidence demonstrates that there was no event, injury, or disease manifesting a heart disability during active service; and that symptoms of the claimed disorder were not continuous or recurrent in service. As noted above, while service treatment records show that the Veteran reported several episodes of heart palpitations, no underlying cardiac disability was found on clinical examination. Moreover, the preponderance of the evidence demonstrates that symptoms of the claimed disorder have not been continuous or recurrent since separation from active service in August 1976. Indeed, the first documented treatment for heart symptoms was in 2010. The absence of post-service complaints, findings, diagnosis, or treatment for the claimed disorder for 34 years after service separation is one factor that tends to weigh against a finding of continuous or recurrent symptoms of a heart disability after service separation. See Buchanan, 451 F.3d 1336 (the lack of contemporaneous medical records is one fact the Board can consider and weigh against the other evidence, although the lack of such medical records does not, in and of itself, render the lay evidence not credible). Additional evidence demonstrating that symptoms of the claimed disorder have not been continuous since service separation is the March 2010 treatment records indicating that the Veteran reported a several week history of heart palpitations, weighing against a finding of continuous symptoms since active service. With regard to the Veteran's recent assertions made in the context of the current disability claim that he has had continuous or recurrent symptoms of the claimed disorder since service, the Board finds that, while the Veteran is competent to report the onset of symptoms of the claimed disorder, these more recent assertions are outweighed by the other, more contemporaneous, lay and medical evidence of record, both in service and after service, and are not reliable. See Charles v. Principi, 16 Vet. App. 370 (2002). The Board finds that the Veteran's assertions of continuous or recurrent symptoms of a heart disability after service are not accurate because they are outweighed by other evidence of record that includes the more contemporaneous service treatment records, which show a report of heart palpitations but no underlying heart disability; the lack of any documentation of reports or treatment for heart palpitations until 2010, 34 years after service separation; and the March 2010 treatment records showing that the Veteran reported palpitations for only several weeks. As such, the Board does not find that the evidence sufficiently supports continuous or recurrent symptomatology of the claimed disorder since service, so as to warrant a grant of service connection. The Board acknowledges the Veteran's belief that his current heart palpitations are related to active service. However, his statements alone do not establish a medical nexus. Indeed, while the Veteran is competent to provide evidence regarding matters that can be perceived by the senses, he is not shown to be competent to render medical opinions on questions of etiology. See Jandreau; see also Barr, 21 Vet. App. 303 (lay testimony is competent to establish the presence of observable symptomatology). As such, as a lay person, he is without the appropriate medical training and expertise to offer an opinion on a medical matter, including the diagnosis, etiology, or causation of a specific disability. The question of diagnosis and causation, in this case, involves complex medical issues that the Veteran is not competent to address. Jandreau. Moreover, the Board finds that no medical opinions are of record supporting a relationship between the Veteran's current heart palpitations and active service, nor is there any other indication in the medical evidence of record that there is a relationship between the current claimed disorder and active service. As noted above, the May 2012 VA examiner opined that the Veteran's current cardiac dysrhythmias are not related to active service, including to the palpitations he experienced during active service. The Board finds this examination report to be the most probative evidence of record, as it is based on an interview and examination of the Veteran and is supported by thorough rationale and citations to the medical evidence of record. Moreover, there are no contrary opinions of record. As also noted above, the Board notes that cardiac dysrhythmias are not listed among the diseases presumptively related to herbicide exposure in service, so a medical nexus for the claimed heart disability may not be presumed as a matter of law under the provisions of 38 C.F.R. § 3.309(e). Moreover, the weight of the evidence is against a finding that he was exposed to Agent Orange or other herbicides during active service, in that it does not demonstrate that he set foot in Vietnam or was otherwise exposed to herbicides. He has not contended that he served in Vietnam, nor does his DD Form 214 indicate that he served there. Further, he did not receive any medals which would indicate in-country service. The Board notes that even if herbicide exposure was conceded, no examining or treating physician has found that the current cardiac dysrhythmias are related to herbicide exposure in service, nor does the evidence of record suggest such a relationship. In sum, the weight of the competent evidence demonstrates that there is no relationship between the Veteran's heart condition and active service. Based on the evidence of record, the weight of the evidence demonstrates no relationship between the Veteran's current claimed heart condition and his military service, including no credible evidence of continuous or recurrent symptoms of the claimed disorder during active service, continuous or recurrent symptomatology of the claimed disorder following service separation, or competent medical evidence establishing a link between the current cardiac dysrhythmias and active service. Therefore, the Board finds that a preponderance of the lay and medical evidence that is of record weighs against the claim for service connection for a heart condition manifested by heart palpitations, and outweighs the Veteran's more recent contentions regarding in-service continuous or recurrent symptoms and continuous or recurrent post-service symptoms. For these reasons, the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Dismissal of Alopecia Areata Claim The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C. § 7105. An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 20.204. Withdrawal may be made by the appellant or by his or her authorized representative. 38 C.F.R. § 20.204. In the present case, at the March 2017 Board hearing, the Veteran withdrew the appeal as to entitlement to service connection for alopecia areata, and, hence, there remain no allegations of errors of fact or law for appellate consideration. Accordingly, the Board does not have jurisdiction to review the appeal regarding that issue, and it is dismissed. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C. §§ 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). VA's duty to notify was satisfied by way of a July 2010 letter. The Board is also satisfied VA has made reasonable efforts to obtain relevant records and evidence. Specifically, the information and evidence that has been associated with the claims file includes the Veteran's service treatment records, post-service VA and private treatment records, a VA opinion with regard to the heart disability claim, and the Veteran's statements, including his testimony at the March 2017 Board hearing. The Court held in Bryant v. Shinseki, 23 Vet. App. 488 (2010), that 38 C.F.R. 3.103(c)(2) requires that the RO official or VLJ who conducts a hearing fulfill two duties to comply with the above regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the March 2017 Board hearing, the undersigned Veterans Law Judge asked questions pertaining to the criteria necessary for establishing his claims, including regarding specific evidence that may help substantiate his claims. Moreover, neither the Veteran, nor his representative, has asserted that VA failed to comply with 38 C.F.R. 3.103(c)(2), nor has he identified any prejudice in the conduct of the Board hearing. As such, the Board finds that, consistent with Bryant, the Veterans Law Judge complied with the duties set forth in 38 C.F.R. 3.103(c)(2), and that any error in notice provided during the hearing constitutes harmless error. As noted above, a VA examination and opinion was obtained in May 2012 with regard to the heart disability claim. To that end, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr at 312. The Board finds that the 2012 VA examination obtained in this case is adequate. The opinion was predicated on a full reading of the private and VA medical records in the Veteran's claims file, as well as an interview and physical examination of the Veteran. The VA nexus opinion considered all of the pertinent evidence of record, to include VA and service treatment records, comprehensive physical examinations, and the statements of the Veteran, and provides a complete rationale for the opinion stated, relying on and citing to the records reviewed. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the heart disability claim has been met. 38 C.F.R. § 3.159(c)(4). The Board acknowledges that the Veteran has not been afforded a VA medical examination specifically geared to the claimed service connection for swollen joints and arthritis of the knees, left ankle, hips, shoulders, and elbows, or a respiratory disability; however, the Board finds that a VA examination is not necessary in order to decide these issues. In McLendon v. Nicholson, 20 Vet. App. 79 (2006), the Court held that in disability compensation claims, the Secretary must provide a VA medical examination when there is: (1) competent evidence of a current disability or persistent or recurring symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent recurrent symptoms of a disability may be associated with the veteran's service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the Secretary to make a decision on a claim. In this case, as discussed above, the Veteran's service treatment records are negative for any complaints of or treatment for disabilities of the knees, left ankle, hips, shoulders, or elbows, or a respiratory disability. Thus, the weight of the evidence demonstrates that the Veteran did not sustain an injury, disease, or event relating to those disabilities in service, and there is no duty to provide a VA medical examination. See Bardwell v. Shinseki, 24 Vet. App. 36, 40 (2010) (holding that that where the evidence has failed to establish an in-service injury, disease, or event, VA is not obligated to provide a medical examination). As explained in this decision, the Board also finds that the weight of the evidence demonstrates no continuous or unremitting symptoms of these disabilities in service and no continuity of symptoms of these disabilities since service separation, and that the weight of the evidence demonstrates no current disabilities of the knees, left ankle, hips, shoulders, or elbows, or a current respiratory disability. Because there is no in-service injury or disease to which a competent medical opinion could relate a current disability, and no current disabilities, there is no reasonable possibility that a VA examination or opinion could aid in substantiating the current claim for service connection. See 38 U.S.C. § 5103A(a)(2) (VA "is not required to provide assistance to a claimant . . . if no reasonable possibility exists that such assistance would aid in substantiating the claim"); 38 C.F.R. § 3.159(d) (VA to discontinue assistance where there is "no reasonable possibility that further assistance would substantiate the claim"). The Board has considered the decision in Charles v. Principi, 16 Vet. App. 370, 374-75 (2002); however, in the absence of evidence of an in-service disease or injury and a current disability, referral of this case to obtain an examination and/or an opinion as to the etiology of the claimed swollen joints and respiratory disability would be a useless act. The duty to assist by providing a VA examination or opinion is not invoked in this case because there is no reasonable possibility that such assistance would aid in substantiating the claim. See 38 U.S.C. § 5103A(a)(2); 38 C.F.R. § 3.159(d). Notably, the Veteran has not identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). ____________________________________________ JONATHAN B. KRAMER Veterans Law Judge, Board of Veterans' Appeals ATTORNEY FOR THE BOARD T. Sherrard, Counsel Copy mailed to: Disabled American Veterans Department of Veterans Affairs