Citation Nr: 21050027 Decision Date: 08/13/21 Archive Date: 08/13/21 DOCKET NO. 05-11 185 DATE: August 13, 2021 ORDER Service connection for a chronic sinus condition is denied. Service connection for a bilateral knee condition is denied. Service connection for a low back condition is denied. Service connection for a gastrointestinal (GI) condition, including gastroesophageal reflux disease (GERD), acid reflux, and hiatal hernia; to include as secondary to service-connected post-traumatic stress disorder (PTSD); is denied. Service connection for a traumatic brain injury (TBI) is denied. Service connection for hypertension, as secondary to service-connected disabilities, is denied. Service connection for tremors of the hands, to include as due to herbicide exposure and/or secondary to service-connected malaria and/or PTSD, is denied. A compensable rating for residuals of malaria is denied. REMANDED The issue of a compensable rating for shell fragment wounds, to include a superficial scar on the right distal leg and right thumb, is remanded. The issue of a rating higher than 50 percent for PTSD is remanded. The issue of a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran's chronic sinus condition did not originate during service, was not caused by any in-service event, injury, disease, or disorder, and did not manifest to a compensable degree within one year of service separation. 2. The Veteran's bilateral knee condition did not originate during service, was not caused by any in-service event, injury, disease, or disorder, and did not manifest to a compensable degree within one year of service separation. 3. The Veteran's low back condition did not originate during service, was not caused by any in-service event, injury, disease, or disorder, and did not manifest to a compensable degree within one year of service separation. 4. The Veteran's GI condition did not originate during service, was not caused by any in-service event, injury, disease, or disorder; and is not caused or aggravated by the service-connected PTSD. 5. The preponderance of the evidence of record is against finding that the Veteran has had a diagnosis of a TBI at any time during or approximate to the pendency of the claim. 6. The preponderance of the evidence of record is against finding that the Veteran has had a diagnosis of hypertension at any time during or approximate to the pendency of the claim. 7. The Veteran's bilateral hand tremor did not originate during service, was not caused by any in-service event, injury, disease, or disorder, to include herbicide exposure; and is not caused or aggravated by the service-connected malaria and/or PTSD. 8. The Veteran's malaria is not shown to be currently active or productive of residual liver impairment, spleen impairment, or other significant and non-transient residuals. CONCLUSIONS OF LAW 1. The criteria to establish entitlement to service connection for a chronic sinus condition have not been met. 38 U.S.C. §§ 1110, 1112, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309. 2. The criteria to establish entitlement to service connection for a bilateral knee condition have not been met. 38 U.S.C. §§ 1110, 1112, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309. 3. The criteria to establish entitlement to service connection for a low back condition have not been met. 38 U.S.C. §§ 1110, 1112, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309. 4. The criteria to establish entitlement to service connection for a GI condition, to include as secondary to the service-connected PTSD, have not been met. 38 U.S.C. §§ 1110, 1154, 5107; 38 C.F.R. §§ 3.102, 3.310(a), 3.303, 3.304. 5. The criteria to establish entitlement to service connection for a TBI have not been met. 38 U.S.C. §§ 1110, 1112, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309. 6. The criteria to establish entitlement to service connection for hypertension, as secondary to service-connected disabilities, have not been met. 38 U.S.C. §§ 1110, 1154, 5107; 38 C.F.R. §§ 3.102, 3.310(a), 3.303, 3.304. 7. The criteria to establish entitlement to service connection for bilateral hand tremor, to include due to herbicide exposure and/or as secondary to service-connected malaria and/or PTSD, have not been met. 38 U.S.C. §§ 1110, 1154, 5107; 38 C.F.R. §§ 3.102, 3.310(a), 3.303, 3.304, 3.309. 8. Throughout the entire period on appeal, the criteria for a compensable rating for malaria have not been met. 38 U.S.C. §§ 1155, 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 4.7, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 6304. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from December 1968 to July 1970, including service in the Republic of Vietnam (RVN). This matter was before the Board of Veterans' Appeals in May 2018 and remanded to the Regional Office (RO), in part, for consideration of new evidence generated by VA. The issues of service connection for a chronic sinus condition, a bilateral knee condition, a low back condition, a GI condition, a TBI, and a compensable rating for malaria were remanded for new VA examinations and/or medical opinions. For the reasons discussed below, service connection will be denied for a chronic sinus condition, a bilateral knee condition, a low back condition, a GI condition, a TBI, hypertension, and tremors of the hands. A compensable rating for residuals of malaria will also be denied. The issues of a compensable rating for shell fragment wounds and a rating higher than 50 percent for PTSD will be remanded for new VA examinations. The issue of a TDIU will be remanded because the issue may be impacted by adjudication of the remanded issues. Service Connection The Board applies the law enacted by Congress and published in Title 38, United States Code ("38 U.S.C."); regulations established by VA and published in the Title 38 of the Code of Federal Regulations ("38 C.F.R.") and rulings of the Court of Appeals for the Federal Circuit (as noted by citations to "Fed. Cir.") and the Court of Appeals for Veterans Claims (as noted by citations to "Vet. App."). Service connection may be granted for a current disability arising from disease or injury incurred or aggravated by active service. 38 U.S.C. §§ 1110. Service connection may be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. §§ 3.303(d). Service connection generally requires (1) medical 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) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The Veteran served in combat while in Vietnam. Because he is a combat veteran, his account of events occurring in combat is presumed credible. In part, this is because the law recognizes that record keeping is not completely reliable in combat. 38 U.S.C.A. § 1154(b) (in the case of any veteran who has engaged in combat with the enemy in active service during a period of war, satisfactory lay or other evidence that an injury or disease was incurred or aggravated in combat will be accepted as sufficient proof of service connection if the evidence is consistent with the circumstances, condition or hardships of such service, even though there is no official record of such incurrence or aggravation. Every reasonable doubt shall be resolved in favor of the Veteran). 38 U.S.C.A. § 1154(b). However, 38 U.S.C. § 1154 (b) only provides a presumption that relevant events occurred in service - not to link the claimed service incidents to the current disorder. See Libertine v. Brown, 9 Vet. App. 521, 522-23 (1996). Section 1154 (b) does not establish service connection for a combat veteran; it aids the veteran by relaxing the evidence required for determining what happened in service. A veteran must still generally establish his claim by competent medical evidence tending to show a current disability and a nexus between that disability and those service events. Gregory v. Brown, 8 Vet. App. 563 (1996). Service connection may also be granted for a disability that is proximately due to, or the result of, a service-connected disability. See 38 C.F.R. § 3.310(a). For secondary service connection, the record must show (1) evidence of a current disability, (2) evidence of a service-connected disability, and (3) medical nexus evidence establishing a connection between the current disability and the service-connected disability. Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995). Certain disorders, listed as "chronic" in 38 C.F.R. § 3.309(a) and 38 C.F.R. § 3.303(b), are capable of service connection based on a continuity of symptomatology without respect to an established causal nexus to service. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Hypertension, arthritis, and malignant tumor are among the chronic diseases listed under 38 C.F.R. § 3.309(a), and therefore presumptive service connection provisions based on "chronic" in-service symptoms and "continuous" post-service symptoms under 38 C.F.R. § 3.303(b) apply. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Where the evidence shows a "chronic disease" in service or "continuity of symptoms" after service, the disease shall be presumed to have been incurred in service. 38 C.F.R. § 3.303(b). Additionally, where a veteran served ninety days or more of active service, and certain chronic diseases, such as hypertension arthritis, and malignant tumor, become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). While the disease need not be diagnosed within the presumptive period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. Id. 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 C.F.R. § 3.307(a)(6)(iii). Given the Veteran's service in the Republic of Vietnam during the presumptive period, his exposure to herbicide agents is presumed. To benefit from the presumption of service connection for diseases associated with herbicide exposure, the Veteran must have one of the diseases listed in 38 C.F.R. § 3.309(e). However, the Veteran's claimed conditions are not among the diseases listed. Id. Therefore, presumptive service connection due to herbicide agent exposure is not warranted. However, the Veteran is not prevented from establishing service connection on a direct basis. Combee v. Brown, 34 F.3d 1039, 1042 (Fed Cir. 1994). In deciding an appeal, the Board must first determine the competency of evidence. "Competency" means that the person who makes the statement is qualified by training, education, an occupation, or other reason to make the statement. For example, medical professionals are generally competent through training and experience to express opinions about whether a disability was caused by service. Generally, the opinions of medical professionals such as doctors, psychiatrists, nurses, and others who work in the health care field are evaluated by their apparent training, as well as the detail of their reports and knowledge of the facts in individual cases. Medical professionals may also report various findings of laboratory studies and clinical testing that could be evidence in a claim, such as the level of hearing impairment, blood tests, range of motion testing in joint pain, etc. If a person making a statement is not medically trained (i.e., a "layperson"), the Board must determine in individual cases whether a veteran's particular disability is the type where a layperson's statement may be competent. See Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). A veteran is competent to report symptoms because they require only personal knowledge of what is observed through senses and not medical expertise. Lay testimony is competent to establish the presence of observable symptoms, where the determination is not medical in nature and is capable of lay observation. Lay evidence may establish a diagnosis of a simple medical condition, a contemporaneous medical diagnosis, or symptoms that later support a diagnosis by a medical professional. See Jandreau, 492 F.3d at 1377. If the Board finds that the evidence is competent, it must then determine whether the evidence is credible. Credibility is a factual determination it involves deciding whether the testimony or other evidence is believable. Whether a statement is credible is decided after the evidence has been found competent. Rucker v. Brown, 10 Vet. App. 67, 74 (1997). The Board must decide whether the evidence supports the claim, with the veteran prevailing; 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. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C. §§ 5107(b). 1. Service connection for a chronic sinus condition is denied. The Veteran contends that his sinus condition is related to his service in Vietnam from the inhalation of dust and dirt while near helicopters, inhalation of smoke and gun powder residue, and exposure to extreme heat and mold. While the Veteran's account of being exposed to dust and dirt while on combat service is presumed credible (i.e., the "in service event"), the claim will be denied because the preponderance of the informed and competent evidence is against the claim. A February 2002 private medical record shows a diagnosis of sinusitis. A May 2004 private medical record shows chronic nasal obstruction likely related to a combination of anatomic abnormalities and soft tissue edema due to allergic rhinitis, with a possible history of chronic recurrent sinusitis. A July 2004 private medical letter from Dr. R.L.C. states that the Veteran has been a patient since 1999 (i.e. starting about 19 years after the Veteran was discharged from service), and that the Veteran had chronic ongoing sinus difficulties, drainage, and intermittent infections, which the Veteran reported having had since his service. The examiner's stated belief was that the condition is related to the Veteran's service in Vietnam. However, the examiner appears to have based the opinion entirely on the Veteran's report of having a sinus condition since his service. The Veteran's service records were not discussed. The Veteran's service treatment records do not contain complaints, treatment, or a diagnosis of any upper respiratory condition, and the May 1970 report of medical examination at service separation shows a normal clinical evaluation of the sinuses. In fact, no medical records before 1999 appear to have been considered. Other than the examiner's stated belief that the condition is related to the Veteran's service, based on the Veteran's report of symptoms since service and treatment since 1999, the opinion provides no other detail as to how the opinion was reached. Therefore, the opinion is of low probative value. Prejean v. West, 13 Vet. App. 444 (2000) During an October 2012 VA examination, the examiner noted a diagnosis of allergic rhinitis and a septal deviation with nasal obstruction, without sinusitis. The examiner opined that it is less than likely that the Veteran's upper respiratory conditions are related to his service. The examiner noted that the service treatment records are silent for any upper respiratory conditions, and that the records do not show any upper respiratory conditions that date to service. The examiner also noted that the Veteran did not report that his upper respiratory symptoms date to his service, and instead the May 2004 private medical record shows upper respiratory symptoms had been present for several years. During a December 2014 VA examination, the examiner noted a diagnosis of hypertrophy of inferior turbinates with mild atraumatic septal deviation, with a date of diagnosis of 2004. The examiner also noted that the Veteran had a previous diagnosis of intermittent allergic rhinitis, which has since resolved. The Veteran reported that he was exposed to wind from the blades of helicopters that created dust, dirt, and mud everywhere causing him to breathe in the dirt while in Vietnam. However, the examiner noted that there were no complaints that show the Veteran had any upper respiratory complaints in-service, to include at separation, and there are no records that show continuity of any upper respiratory condition dating to his service. The examiner noted that the first post-service documentation of upper respiratory symptoms was in 2004. The examiner opined that the etiology of the Veteran's chronic sinusitis is a bacterial infection in the sinus cavity, which can be visualized on CT scan, and is accompanied by frequent complaints of purulent nasal drainage; treated with antibiotics. The examiner noted that the Veteran's 2011 sinus CT scan was within normal limits; therefore, a diagnosis of chronic sinusitis is not found. The examiner noted that if a sinus condition becomes chronic, CT imaging would show mucosal thickening of the lining of sinus, or fluid in the involved sinus cavity. The examiner noted that the Veteran complained that his left nostril is slowly closing, but that he has never had a trauma with broken septum. The examiner noted that current physical findings are consistent with decreased size of left nasal passage due to hypertrophy of inferior turbinate and mild septal deviation. The examiner noted that records from 2004 show reported nasal congestion for several years with intermittent sinus infections based on the history reported by the Veteran, and that frequent allergy symptoms were reported such as sneezing, congestion, headache, and itching eyes that worsened in the spring and fall. However, the examiner noted that the Veteran's symptoms were not related to his service, and instead the assessment was chronic nasal obstruction likely secondary to septal deviation and allergic rhinitis. The examiner noted that the Veteran could not remember when he was last treated with antibiotics for upper respiratory symptoms and his records do not show frequent or repeated use of antibiotics to treat a bacterial sinus infection. The examiner stated that the Veteran's symptoms when last evaluated for allergic rhinitis have not been treated, and allergic rhinitis can wax and wane over time, or may resolve, as it appears with this Veteran. During a January 2019 VA examination, the examiner noted diagnoses since January 2004, include acute chronic sinusitis; URI/sinusitis; acute sinobronchitis; chronic nasal obstruction, secondary to septal deviation and allergic rhinitis; ongoing sinus difficulties with drainage and intermittent infections; chronic hypertrophy of inferior turbinates with mild atraumatic septal deviation; intermittent allergic rhinitis, resolved; and septal deviation with nasal obstruction. The examiner noted that a 2011 CT scan of the sinuses was negative for any findings of sinusitis. The examiner noted that the Veteran's last treatment for sinusitis was in October 2017 when the Veteran was prescribed Doxycycline for seven days when he presented with a four-to-five-day history of sinus pressure, cough, and other symptoms of an upper respiratory infection. The examiner noted that there is no persistent, recurrent, or chronic sinusitis documented in the medical record. The examiner noted that the Veteran is not currently on any medications for allergic rhinitis or any other upper respiratory conditions such as sinusitis, and the recent treatment records do not reflect any ongoing problems with any sinus or upper respiratory conditions. The examiner opined that it is less than likely that the above diagnoses, or any other sinus, ENT, or upper respiratory conditions that the Veteran may develop, were incurred in-service or are otherwise related to his service, including exposure to dust and dirt from helicopters flying nearby, smoke, gun powder residue, or extreme heat and mold while in Vietnam. The examiner noted that there is no current acute or chronic sinusitis or allergic rhinitis reflected in the treatment records. The examiner stated that although the Veteran has had transient episodes of sinusitis and upper respiratory infections in the past, the character and frequency is not outside the normal range. The examiner stated that there is no current indication that there are any chronic sinus disabilities. The examiner noted that the Veteran did not describe upper respiratory symptoms or symptoms of any of the above diagnoses that started on active service or that date to service. The examiner stated that there is no medical literature that supports that there is delayed onset of allergic rhinitis symptoms after exposure to environmental allergens such as dust, smoke, etc. The examiner noted that the service treatment records are silent for any of the listed upper respiratory conditions, and the post-service records do not show any upper respiratory conditions that date to service. The examiner noted that the May 2004 VA ENT consultation show that upper respiratory symptoms had been present for several years, and that symptoms were not described as dating to service, which was over 30 years prior to 2004. The examiner also stated that nasal obstruction due to allergic rhinitis and septal deviation are not shown by history or a record review to date to service, and the history and records do not show that there was any nasal trauma in-service to account for the septal deviation. The preponderance of the evidence is against the claim and the appeal will be denied. The service treatment records do not show complaints, treatment, or a diagnosis of any upper respiratory condition, and the May 1970 report of medical examination at service separation shows a normal clinical evaluation of the sinuses. Post-service medicals records show that the Veteran was diagnosed with sinusitis in 2002. A February 2002 private medical record shows a diagnosis of sinusitis. A May 2004 private medical record shows chronic nasal obstruction likely related to a combination of anatomic abnormalities and soft tissue edema due to allergic rhinitis, with a possible history of chronic recurrent sinusitis. Although the July 2004 private medical examiner stated that the condition is related to the Veteran's service in Vietnam, the opinion provides no other detail as to how the opinion was reached. The October 2012 VA examiner opined that it is less than likely that the Veteran's upper respiratory conditions are related to his service. The examiner noted that the service treatment records are silent for any upper respiratory conditions, and that the records do not show any upper respiratory conditions that date to service. The examiner also noted that the Veteran did not report that his upper respiratory symptoms date to his service, and instead the May 2004 private medical record shows upper respiratory symptoms had been present for several years. The December 2014 VA examiner opined that the etiology of the Veteran's chronic sinusitis is a bacterial infection in the sinus cavity. The examiner noted that the Veteran complained that his left nostril is slowly closing, but that he has never had a trauma with broken septum. The examiner noted that current physical findings are consistent with decreased size of left nasal passage due to hypertrophy of inferior turbinate and mild septal deviation. The examiner noted that records from 2004 show reported nasal congestion for several years with intermittent sinus infections based on the history reported by the Veteran, and that frequent allergy symptoms were reported such as sneezing, congestion, headache, and itching eyes that worsened in the spring and fall. However, the examiner noted that the Veteran's symptoms were not related to his service, and instead the assessment was chronic nasal obstruction likely secondary to septal deviation and allergic rhinitis. The January 2019 VA examiner opined that it is less than likely that the above diagnoses, or any other sinus, ENT, or upper respiratory conditions that the Veteran may develop, were incurred in-service or are otherwise related to his service, including exposure to dust and dirt from helicopters flying nearby, smoke, gun powder residue, or extreme heat and mold while in Vietnam. The examiner noted that the Veteran did not describe upper respiratory symptoms, or symptoms of any of the above diagnoses, that started on active service or that date to service. The examiner stated that there is no medical literature that supports that there is delayed onset of allergic rhinitis symptoms after exposure to environmental allergens such as dust, smoke, etc. The examiner noted that the service treatment records are silent for any of the listed upper respiratory conditions, and the post-service records do not show any upper respiratory conditions that date to service. The examiner noted that the May 2004 VA ENT consultation shows that upper respiratory symptoms had been present for several years, and that symptoms were not described as dating to service, which was over 30 years prior to 2004. The examiner also stated that nasal obstruction due to allergic rhinitis and septal deviation are not shown by history or a record review to date back to service, and the history and records do not show that there was any nasal trauma in-service to account for the septal deviation. While the Veteran believes that his current condition is related to his service, he is not competent to establish a nexus between his current condition and his service. The issue is medically complex, as it requires specialized medical knowledge. Therefore, it is outside the competence of the Veteran because the record does not show that he has the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). The Veteran's service treatment records do not show any complaints, treatment, or diagnosis of an upper respiratory condition, to include his separation examination, which was normal. The Veteran contends that his sinus condition is related to his service in Vietnam, due to inhalation of dust and dirt while near helicopters, inhalation of smoke and gun powder residue, and exposure to extreme heat and mold. However, post-service medical records show that the Veteran was not diagnosed with sinusitis until 2002. The Veteran's medical records are highly probative both as to the Veteran's subjective reports and their resulting objective findings. They were generated with a view towards ascertaining the Veteran's then-state of physical fitness and are akin to statements of diagnosis or treatment. Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (observing that although formal rules of evidence do not apply before the Board, recourse to the Federal Rules of Evidence may be appropriate if it assists in the articulation of the reasons for the Board's decision); see also LILLY'S: AN INTRODUCTION TO THE LAW OF EVIDENCE, 2nd Ed. (1987), pp. 245-46 (many state jurisdictions, including the federal judiciary and Federal Rule 803(4), expand the hearsay exception for physical conditions to include statements of past physical condition on the rationale that statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy since the declarant has a strong motive to tell the truth in order to receive proper care). Although the record shows that the Veteran has had several upper respiratory conditions post-service, the preponderance of the evidence weighs against a finding that his conditions are causally related to his service. Instead, none of the VA examiners of record associated the any of the Veteran's upper respiratory conditions with his service, to include inhalation of dust and dirt while near helicopters, inhalation of smoke and gun powder residue, and exposure to extreme heat and mold in Vietnam. Since the preponderance of the evidence is against the claim, the benefit-of-the-doubt rule is not applicable. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990); 38 C.F.R. § 3.102. For these reasons, the claim is denied. 2. Service connection for a bilateral knee condition is denied. The Veteran contends that his bilateral knee condition is related to his service, due to frequent helicopter jumps and carrying heavy equipment. While his account of jumping from helicopters in combat is presumed credible, the preponderance of the informed, competent evidence is against the claim and the appeal will be denied. A July 2004 private medical letter from Dr. R.L.C. states that the Veteran has arthritic changes in the bilateral knee, which is related to an injury that occurred from helicopter jumps. This opinion is of low probative value since the examiner appears to have based the opinion entirely on the Veteran's report that his bilateral knee condition onset in-service because of helicopter jumps. In fact, the Veteran's service records were not discussed. Other than the examiner's stated belief that the condition is related to the Veteran's service, based on the Veteran's report, the opinion provides no other detail as to how the opinion was reached. Therefore, the opinion is of low probative value. Prejean, 13 Vet. App. at 444. VA imaging from 2012 shows minimal early age-appropriate degenerative joint disease, which is most prominent in the patellofemoral compartments bilaterally. An August 2008 VA medical record shows that the Veteran had a right knee laparoscopic meniscus surgery done few weeks previously and was still going through an extensive healing process with physical therapy. The Veteran's service treatment records do not contain complaints, treatment, or diagnoses of any knee condition, and the May 1970 report of medical examination at service separation shows a normal clinical evaluation of the lower extremities. During an October 2012 VA examination, the Veteran reported a right knee injury following a motor vehicle accident (MVA) that occurred seven years prior. The examiner noted a diagnosis of patellofemoral pain syndrome. The Veteran reported that his knees began to hurt post-service while employed at the sheriff's office. However, the examiner noted that the Veteran did not report any specific injury to his knees other than the MVA. The examiner noted that a bilateral knee x-ray shows minimal early age-appropriate degenerative joint disease. The examiner also noted that the Veteran reported having had a right knee meniscectomy. However, the examiner noted that there is no record of the reported surgery in the claims file. The examiner noted that the meniscal injury leading to the surgery was sustained in the post-service work-related MVA. The examiner opined that it is less than likely that the knee conditions are the result of injury or disease incurred or aggravated in-service. The examiner noted that service treatment records are silent for any treatment or symptoms of knee conditions; the separation examination does not identify any knee abnormalities; the Veteran did not report that any knee injury occurred in-service; there are no medical records that show any chronic knee condition that dates back to service; and the Veteran was in a work-related MVA after his service when his right knee was injured. During a December 2014 VA examination, the examiner noted a diagnosis of left knee minimal degenerative joint disease and right knee post-service traumatic injury status post partial meniscectomy with mild degenerative joint disease. The Veteran reported that while in Vietnam, he was required to make about one jump per week out of a helicopter that was hovering near the ground, and his jumps were made while wearing gear including a radio, batteries, and other required gear that could weigh 65-70 pounds. The examiner noted that there were no complaints or treatment for any knee condition in-service. The examiner noted that the Veteran had a work-related injury due to a MVA when he injured his back and right knee in 2007. The Veteran reported that his left knee has not had any post-service injury, but that he had onset of aching, which worsened in the past 10 years. The examiner noted that the Veteran had chronic mild diffuse pain around his entire patellar area of the bilateral knee. The examiner opined that it is less likely than not that the Veteran's current bilateral knee disorders had onset during, or were caused or aggravated by his service, and it is less likely than not that any knee pathology currently found is due to jumping out of helicopters in-service. The examiner noted that the service treatment records are silent for any bilateral knee pain or abnormalities, and the separation examination does not identify any knee abnormalities. The examiner noted that there are no medical records in the claims folder showing any chronic knee condition that dates to service. The examiner noted that the right knee was in a significant work-related injury in 2007 and required surgical intervention. The examiner noted that recent VA knee imaging showed only minimal early age-appropriate degenerative joint disease in the bilateral knee. The examiner stated that if the Veteran had any significant knee trauma during service while in his early 20s, one would expect more advanced degenerative disease. The examiner noted that several medical providers have stated, in various progress notes, that the Veteran's knee conditions had onset in Vietnam. However, the examiner stated that these comments are based on the history provided by the Veteran, and none of these records indicate that the comments are based on a review of the medical records. During the January 2019 VA examination, the examiner noted that the diagnoses of the Veteran's knee conditions that are reflected in the record since January 2004 include the following: post-service right knee meniscal tear with partial medial meniscectomy in 2008; patellofemoral pain syndrome; degenerative joint disease and osteoarthritis; and left knee meniscal tear. The examiner stated that VA examinations from October 2012 and December 2014 provide thorough histories and detailed discussions of the records regarding the Veteran's knee conditions. The examiner noted that in the last two years, the only record of knee problems was when the Veteran reported that he had left knee pain and a left knee meniscal tear with pending surgery; the examiner noted that no other records pertaining to this were found. The examiner noted that patellofemoral pain syndrome was diagnosed during the October 2012 VA examination. The examiner opined that it is less than likely that any of the Veteran's knee conditions were incurred in-service or are otherwise related to his service, to include his reports of pain after jumping out of helicopters and carrying heavy equipment during service. The examiner stated that the right knee meniscal tear is clearly the result of a post-service injury, which is well documented in the records and discussed in prior VA examinations. The examiner noted that the Veteran's degenerative disc disease and osteoarthritis is more than likely due to the age and genetics related degenerative joint disease that is extremely common in middle-aged and older individuals. The examiner also stated that any left knee meniscal tear is secondary to age-related degeneration, or post-service injury, since no injury sufficient to cause a meniscal tear is reported to have occurred in-service, or noted in the service treatment records, and since the reported left meniscal tear occurred over 40 years after service. The examiner stated that patellofemoral pain syndrome is often caused by abnormal tracking of the patella, commonly found in the general population, and is not due to any remote military duties. The examiner stated that VA examinations in 2012 and 2014 have addressed the question of whether the Veteran's knee conditions are related to service, that the analyses and rationales for these VA examinations continue to hold true, and they apply to any and all circumstances of the Veteran's service, including jumping out of helicopters and carrying heavy equipment. An October 2020 private medical record shows a past bilateral knee arthroscopy surgery. A review of the musculoskeletal system was negative for arthritis. The preponderance of the evidence is against the claim and the appeal will be denied. The service treatment records do not contain complaints, treatment, or diagnoses of any knee condition, to include the medical examination at service separation, which shows a normal clinical evaluation of the lower extremities. The July 2004 private medical opinion stated that the arthritic changes in the bilateral knee are related to an injury that occurred from helicopter jumps. However, the opinion appears to be based entirely on the Veteran's report that his bilateral knee condition onset in-service because of helicopter jumps, without any further detail as to how the opinion was reached. VA imaging from 2012 shows minimal early age-appropriate degenerative joint disease, which is most prominent in the patellofemoral compartments bilaterally. The October 2012 VA examiner opined that it is less than likely that the knee conditions are the result of injury or disease incurred or aggravated in service. The December 2014 VA examiner opined that it is less likely than not that the Veteran's current bilateral knee disorders had onset during or were caused or aggravated by his service, and it is less likely than not that any knee pathology currently found is due to jumping out of helicopters while in-service. The examiner noted that the service treatment records are silent for any bilateral knee pain or abnormalities, and the separation examination shows a normal clinical evaluation of the bilateral lower extremities. The examiner noted that there are no medical records in the claims folder showing any chronic knee condition that dates to service. The examiner noted that the right knee was in a significant work-related injury in 2007 and required surgical intervention. The examiner noted that recent VA knee imaging showed only minimal early age-appropriate degenerative joint disease in the bilateral knee. The examiner stated that if the Veteran had any significant knee trauma during service while in his early 20s, one would expect more advanced degenerative disease. The January 2019 VA examiner opined that it is less than likely that any of the Veteran's knee conditions were incurred in-service or are otherwise related to his service, to include his reports of pain after jumping out of helicopters and carrying heavy equipment during service. The examiner stated that the right knee meniscal tear is clearly the result of a post-service injury, which is well documented in the records and discussed in prior VA examinations. The examiner noted that the Veteran's degenerative disc disease and osteoarthritis is more than likely due to the age and genetics related degenerative joint disease that is extremely common in middle-aged and older individuals. The examiner also stated that any left meniscal tear is secondary to age-related degeneration, or post-service injury, since no injury sufficient to cause a meniscal tear is reported to have occurred in-service, or noted in the service treatment records, and since the reported left meniscal tear occurred over 40 years after service. The examiner stated that patellofemoral pain syndrome is often caused by abnormal tracking of the patella, commonly found in the general population, and is not due to any remote military duties. While the Veteran believes that his current condition is related to his service, he is not competent to establish a nexus between his current condition and his service. The issue is medically complex, as it requires specialized medical knowledge. Therefore, it is outside the competence of the Veteran because the record does not show that he has the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Reiterating, the Veteran's account of disembarking from helicopters in combat conditions is presumed credible and does not require substantiation as in the case of a non-combat veteran. However, to the extent that the Veteran has alleged continuous symptoms since those incidents, his service treatment records do not contain complaints, treatment, or diagnoses of any knee condition, to include the medical examination at service separation, which shows a normal clinical evaluation of the bilateral lower extremities. See Rucker, supra. The first post-service medical record of any knee condition is from July 2004. VA imaging from 2012 shows minimal early age-appropriate degenerative joint disease, which is most prominent in the patellofemoral compartments bilaterally. There is no medical evidence of record that shows that any of the Veteran's bilateral knee conditions have been ongoing since his service. Therefore, service connection based on a continuity of symptomatology is not warranted. Although the record shows that the Veteran has several diagnosed disorders of both knees, the preponderance of the evidence weighs against a finding that any of the conditions are causally related to his service, to include frequent helicopter jumps and carrying heavy equipment while in Vietnam. Instead, none of the VA examiners of record associated any of the conditions with the Veteran's service, to include frequent helicopter jumps and carrying heavy equipment while in Vietnam. Since the preponderance of the evidence is against the claim, the benefit-of-the-doubt rule is not applicable. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990); 38 C.F.R. § 3.102. For these reasons, the claim is denied. 3. Service connection for a low back condition is denied. The Veteran contends that his low back condition is related to his service, due to frequent helicopter jumps and a "bad jump" that occurred after parachuting. For the following reasons, the preponderance of the informed, competent evidence is against the claim and service connection for a low back condition is denied. November 2003 magnetic resonance imaging (MRI) results show mild desiccation of the L4/L5 intervertebral discs. A November 2003 private medical record shows that the Veteran reported that he has had low back pain for many years. The Veteran reported his belief that his low back condition is related to his service in Vietnam when carrying heavy loads as a radio operator. He reported that he had no specific injury in-service, and instead reported that his pain gradually onset. He reported that he had a modest amount of pain during and immediately following his service, but that in his adult life, the pain was not terribly debilitating until recently. A July 2004 private medical letter from Dr. R.L.C. states that the Veteran has low back pain, which has been ongoing since his service. The examiner's stated belief was that the condition is related to the Veteran's service in Vietnam. This opinion is of low probative value since the examiner appears to have based the opinion entirely on the Veteran's report that his low back pain began in-service. The Veteran's service records were not discussed. Other than the examiner's stated belief that the condition is related to the Veteran's service, based on the Veteran's report, the opinion provides no other detail as to how the opinion was reached. Therefore, the opinion is of low probative value. Prejean, 13 Vet. App. at 444. A November 2004 letter from Dr. R.W. states that she "would not rule out the possibility that [the Veteran's] tour of duty in [Vietnam] may have been the beginning of his degenerative problems." This statement is of no probative value because the opinion is too speculative to establish a medical nexus. Goss v. Brown, 9 Vet. App. 109 (1996); see Tirpak v. Derwinski, 2 Vet. App. 609 (1992) (holding that medical opinions are speculative and of little or no probative value when a physician makes equivocal findings such as "the veteran's death may or may not have been averted"). The Veteran's service treatment records do not contain any complaints, treatment, or diagnosis of any back condition, and the May 1970 report of medical examination at service separation shows a normal clinical evaluation of the spine and musculoskeletal system. During the December 2008 VA examination, the Veteran reported ongoing back pain for 30 years. The Veteran reported that he fell onto his back when a grenade detonated near him while in Vietnam, which VA must presume is credible because the Veteran served in combat. However, the Veteran did not recall any problems with walking or back pain immediately afterward, although he reported that his back bothered him off and on during the remainder of his service. The examiner noted a 2001 medical record showing reported back pain with recent onset. The examiner noted that the Veteran did not report post-service treatment for his back until recently, and he was able to work in jobs that involved at least moderate activity and was able to golf and play tennis in earlier years. The examiner stated that if the Veteran had a back problem dating to his service, it would not be expected that he would have been able to play golf or tennis. The examiner noted that there is no documentation of any treatment for back pain immediately after his discharge. The examiner opined that it is less than likely that the Veteran's current low back condition is related to his service. A December 2009 private medical record shows that the Veteran complained of low back pain, which originated after an MVA. During the October 2012 VA examination, the Veteran complained of constant low back pain. He reported upper lumbar and low thoracic area pain that he has had since an MVA that occurred seven years prior. The Veteran reported that his low back was fine before the MVA and reported that his low back has bothered him for years. He reported that he was thrown backwards when a grenade detonated near him in-service in Vietnam. The examiner noted that the service treatment records do not contain any complaints or treatment for any back condition, including the separation examination. The examiner opined that it is less than likely that the Veterans thoracic and lumbar spine conditions are the result of in-service injury, or disease, or aggravated by his service. The examiner provided the following explanation: the thoracic strain dates to the reported 2007 MVA; the service treatment records are silent for symptoms, treatment, or diagnosis of any back condition; the separation examination does not indicate any abnormalities of the back; there are no medical records that show a chronic back condition dating to service; the Veteran did not report having had back symptoms during service; the reported incident involving a grenade detonation when the Veteran fell onto his back did not cause a significant back injury, given that he does not recall back symptoms at that time, or during the remainder of his service; an October 2003 chiropractic note shows that the Veteran reported that he was doing cartwheels when he heard a pop in his back; a June 2011 chiropractic note shows symptoms of low back pain were first noticed four years ago; and a September 2009 medical record shows an assessment of low back pain originating after an MVA. The examiner stated that the Veteran's low back condition started well after his discharge from service. During the December 2014 VA examination, the Veteran reported that he was required to make about one jump per week out of a helicopter that was hovering near the ground in-service. He reported that the jumps were made while wearing equipment including a radio, batteries, and other required gear that could weigh 65-70 pounds. The examiner noted that the service treatment records do not contain any complaints or treatment for a low back condition. The examiner noted that a November 2003 private medical record shows that the Veteran was evaluated for persistent low back pain, which the Veteran associated with his service in Vietnam when carrying heavy loads. Lumbar spine x-rays showed slight to moderate degenerative disc disease and some degenerative joint disease. An MRI of the lumbar spine revealed mild desiccation of L4/L5 and L5/S1 discs without overt disc herniation, central canal stenosis, or foraminal stenosis. The examiner noted that a November 2004 private medical letter stated that the Veteran had consistent problems with his spine and that she "would not rule out the possibility that his tour of duty may have been the beginning of his degenerative problems." The examiner noted that records showing treatment for a back condition do not appear until the early 2000s, and there was no imaging of Veteran's back until 2003, when he was age 55. The examiner noted that there is documentation of a work-related back injury due to an MVA in September 2007. The examiner noted that a January 2008 orthopedic record shows that the Veteran denied a history of previous back problems prior to his 2007 MVA. The examiner noted that the Veteran reported a "bad jump" after parachuting in Vietnam while taking ground fire; the Veteran reported that he had to get up and run again with a sore back after landing, but that afterward he was able to continue regular combat duties. The examiner noted that the separation examination showed a normal spine, neurologic system, and lower extremities. The examiner noted that the Veteran did not report any specific soreness to the back when a rocket reportedly exploded nearby when he was knocked onto his back such that he "hurt all over." The examiner noted that the Veteran reported chronic pain in the low back that has been worse in the past seven to ten years, which the examiner noted is most consistent with the work-related MVA. The examiner opined that it is less than likely that the Veteran's current degenerative disc disease and degenerative joint disease had its onset during or was caused by his service, that it is also less than likely that his low back condition is the result of carrying supplies in-service, and that it is less than likely that his low back condition is the result of being knocked onto his back by a rocket explosion in-service. The examiner noted that the service treatment records are silent for any low back condition or injury, and the separation physical shows a normal spine examination without indication of any low back condition or injury. The examiner noted that the Veteran's history does not indicate that a significant back injury occurred in-service. The examiner noted that there are no post-service medical records that show a low back condition dating to service, and instead the first record of treatment for low back pain post-service was in 2003, which is over 30 years after discharge. The examiner also noted that the Veteran was in a significant work-related MVA in 2007 when he injured his back. The examiner noted that November 2003 MRI results, which was before the 2007 accident, are not unusual for an individual of the Veteran's age. The examiner stated that the results are not consistent with any remote back trauma but can be considered typical age-related degenerative changes. The examiner noted that the 2004 letter from Dr. R.W. does not indicate that any review of service or post-service medical records was completed, it does not include evidence that any back condition is documented dating to service, and it does not provide any discussion of the Veteran's history, including any in-service injuries, the date of onset, or course of the Veteran's back symptoms. The examiner noted that the letter is not a statement of fact, or even 50-50 certainty; rather, it is one of conjecture and indicates that Dr. R.W. has considerable uncertainty about the cause of the Veteran's degenerative problems. The examiner concluded that 2012 imaging of Veteran's spine nine years after his report of back issues in 2003, and after his 2007 MVA, show an impression of minimal age-appropriate multilevel degenerative disc disease, as well as mild some minimal degenerative joint disease. During the January 2019 VA examination, the examiner noted that diagnoses of the Veteran's spine conditions reflected in the record since June 2004 include the following: neck pain, thoracic pain, low back pain, lumbar spondylosis, degenerative disc disease, facet arthropathy, thoracolumbar degenerative joint disease, chronic low thoracic strain, and chronic lumbar strain. The examiner stated that the December 2014 VA examination provides a thorough history of the Veteran's back condition and includes a detailed discussion of the treatment records related to the back conditions. The examiner noted that treatment records show that, most recently, the Veteran was evaluated by his primary care physician in November 2018 with a complaint of left-side low back pain that started while he was in the hospital earlier in the month. Upper lumbar muscle spasm was noted on examination. The examiner noted that an April 2018 routine primary care visit included complaints of back and leg pain. The examiner noted that a 2018 lumbar MRI showed spondylosis/facet arthropathy, which was noted as unchanged from the 2012 MRI. The examiner noted a primary care progress note from October 2018 shows a complaint of cervical spine pain because of a work-related MVA. The examiner noted that the treatment records do not show any other cervical spine problems in the past two years. The examiner opined that it is less than likely that any of the Veteran's spine conditions were incurred in service or are otherwise related service, including jumping out of helicopters and a reported "bad jump" after parachuting. The examiner noted that multiple prior VA examinations in 2008, 2012, and 2014 address the question of whether the Veteran's back condition is related to his service. The examiner noted that the Veteran did not report jumping out of helicopters with parachute landings as being contributory causes of any back symptoms in those VA examinations. The examiner opined that the Veteran's current spine conditions are more than likely caused by genetics and the aging process, as well as the work-related MVA. The examiner noted that the prior VA examination rationale for this issue continue to hold true; they address the question as to whether the back condition is related to service. An April 2021 VA medical note shows a history of chronic low back pain. The examiner noted that it is unclear whether the Veteran's low back condition is related to his psoriatic arthritis. X-ray imaging shows mild convex left curvature of the lower lumbar spine, with minimal age-appropriate multilevel degenerative disc disease. The preponderance of the evidence is against the claim and the appeal will be denied. The service treatment records do not contain any complaints, treatment, or diagnosis of any back condition, and the May 1970 report of medical examination at service separation shows a normal clinical evaluation of the spine and musculoskeletal system. A November 2003 MRI results show mild desiccation of the L4/L5 intervertebral discs. A November 2003 private medical record shows that the Veteran reported that he has had low back pain for many years. The July 2004 private medical examiner stated that the Veteran's back condition is related to the Veteran's service in Vietnam. However, the examiner appears to have based the opinion entirely on the Veteran's report that his low back pain began in-service. The November 2004 private examiner stated that she "would not rule out the possibility that [the Veteran's] tour of duty in [Vietnam] may have been the beginning of his degenerative problems." However, the opinion is too speculative to establish a medical nexus. The December 2008 VA examiner opined that it is less than likely that the Veteran's current low back condition is related to his military service. The examiner stated that if the Veteran had a back problem dating to service, it would not be expected that he would have been able to play golf or tennis in the years post-service. The examiner noted that there is no documentation of any treatment for back pain immediately after his discharge. The October 2012 VA examiner opined that it is less than likely that the Veteran's thoracic and lumbar spine conditions are the result of in-service injury, or disease, or aggravated by his service. The examiner noted that the thoracic strain dates to the reported 2007 MVA; the service treatment records are silent for symptoms, treatment, or diagnosis of any back condition; the separation examination does not indicate any abnormalities of the back; there are no medical records that show a chronic back condition dating to service; the Veteran did not report having had back symptoms during service; the reported incident involving a grenade detonation when the Veteran fell onto his back did not cause a significant back injury, given that he does not recall back symptoms at that time, or during the remainder of his service; an October 2003 chiropractic note shows that the Veteran reported that he was doing cartwheels when he heard a pop in his back; a June 2011 chiropractic note shows symptoms of low back pain were first noticed four years ago; and a September 2009 medical record shows an assessment of low back pain originating after an MVA. The examiner stated that the Veteran's low back condition started well after the Veteran's discharge from service. The December 2014 VA examiner opined that it is less than likely that the Veteran's current degenerative disc disease and degenerative joint disease had its onset during or was caused by his military service, that it is also less than likely that his low back condition is the result of carrying supplies in-service, and that it is less than likely that his low back condition is the result of being knocked onto his back by a rocket explosion. The examiner noted that the Veteran's history does not indicate that a significant back injury occurred on active duty. The examiner noted that there are no post-service medical records that show a low back condition dating to service, and instead the first record of treatment for low back pain post-service was in 2003, which is over 30 years after discharge. The January 2019 VA examiner opined that it is less than likely that any of the Veteran's spine conditions were incurred in-service, or are otherwise related service, to include jumping out of helicopters and a reported "bad jump" after parachuting. The examiner opined that the Veteran's current spine conditions are more than likely caused by genetics and the aging process, as well as the work-related MVA. While the Veteran believes that his condition is related to his service, he is not competent to establish a nexus between his current condition and his service. The issue is medically complex, as it requires specialized medical knowledge. Therefore, it is outside the competence of the Veteran because the record does not show that he has the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Although, the Veteran contends that his back condition is related to his service, due to frequent helicopter jumps and a "bad jump" that occurred after parachuting, his service treatment records do not contain complaints, treatment, or diagnoses of any back condition, to include the medical examination at service separation, which shows a normal clinical evaluation of the spine and musculoskeletal system. There is no evidence that his back was ever evaluated as abnormal in-service. The Veteran's medical records are highly probative both as to the Veteran's subjective reports and their resulting objective findings. They were generated with a view towards ascertaining the Veteran's then-state of physical fitness and are akin to statements of diagnosis or treatment. Rucker, supra. To the extent that the Veteran contends that service connection is warranted based on continuity of symptomatology, the Veteran's service treatment records are absent of any complaints, treatment, or diagnosis of any back condition, and the first post-service medical record of any back condition is from November 2003. There is no medical evidence of record that shows that any of the Veteran's back conditions have been ongoing since his service. Therefore, service connection based on a continuity of symptomatology is not warranted. Since the preponderance of the evidence is against the claim, the benefit-of-the-doubt rule is not applicable. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990); 38 C.F.R. § 3.102. For these reasons, the claim is denied. 4. Service connection for a GI condition, including GERD, acid reflux, and hiatal hernia; to include as secondary to service-connected PTSD; is denied. The Veteran's original contention was that his GERD is related to service-connected PTSD. The Veteran's current contention is that his GERD is related to his service, from eating outdated rations and inhaling the odor of decaying human flesh in Vietnam. The Veteran reports that his heartburn began in-service and has continued since his service. The preponderance of the competent evidence is against the claim, and the appeal will be denied. In a November 2004 private medical letter, Dr. R.L.C. stated that the Veteran has been a patient since 1999 and that the Veteran has had GI bleeding since then. A November 2007 upper GI study shows a small sliding type hiatus hernia with GERD and low-grade esophagitis. The Veteran's service treatment records do not contain complaints, treatment, or diagnosis of any GI disorder, and the May 1970 report of medical examination at service separation shows a normal clinical evaluation of all systems, without any indication of any GI symptoms or disorder. During the August 2008 VA examination, the Veteran alleged that his condition is related to his PTSD and stated that he has had stomach problems for a long time. The examiner noted the results of the November 2007 upper GI study and opined that the Veteran's condition is not related to his PTSD. The examiner stated that the medical literature does not support a relationship between GERD/hiatal hernia and PTSD. The examiner noted that the Veteran was first diagnosed with the condition in 2004, which was over 30 years after his discharge. The examiner opined that it is less likely than not that the GERD/hiatal hernia is caused by, or a result of PTSD. In the December 2008 VA opinion, the examiner opined that it is less than likely that the Veteran's GERD/hiatal hernia has been aggravated by his service-connected PTSD. The examiner also noted that the Veteran is not on any medications for PTSD that would aggravate GERD. During the October 2012 VA examination, the Veteran reported constant heartburn that is aggravated by spicy and acidic foods. The examiner noted that the Veteran did not mention any PTSD-related issues that cause increased GERD symptoms. The Veteran reported that his GERD symptoms have bothered him for at least ten years. The examiner noted that the Veteran did not report symptoms of GERD that were ongoing since his service. The Veteran reported that he experienced vomiting, belching, and diarrhea in Vietnam from the food that he ate. The examiner noted that a hiatal hernia was documented in a 2004 upper GI study, and that the Veteran has reflux and pyrosis, which are symptoms of GERD. The examiner stated that although the Veteran has had GI bleeds in the past, there is no current acute or chronic GI bleed condition. The examiner opined that it is less than likely that the Veteran's GERD is related to any in-service occurrence or event. The examiner noted that the service treatment records are silent of complaints or treatment for any GI disorder, that there are no medical records that show continuity of GERD symptoms dating back to service, that the Veteran does not describe GERD symptoms on active duty, and that the first mention of GERD symptoms post-service are nearly 30 years after service. During the June 2013 VA examination, the examiner noted that the Veteran treats his PTSD with the use of several medications. The Veteran reported that his medications make him sleepy, but he did not report any GI distress to include GERD symptoms. During the December 2014 VA examination, the Veteran reiterated his symptoms and theory of service connection. However, he reported that he did not seek treatment in-service, and that he "learned to live with it." The examiner noted that during the 2004 VA Agent Orange Registry examination, the only GI symptom that the Veteran reported was constipation. The examiner noted a current diagnosis of GERD, which was noted as the current etiology of the Veteran's GI disorders. The examiner noted that a hiatal hernia was documented in the 2004 esophagogastroduodenoscopy, and that the Veteran has reflux and pyrosis, which are symptoms of GERD. The examiner opined that it is less likely than not that Veteran's GERD had its onset during or was caused by service. The examiner stated that the service treatment records do not show symptoms of or a diagnosis of GERD, and the separation examination is negative for the condition. The examiner noted that there are no medical records that document continuity of any symptoms of GERD dating to service, and the medical records do not show reported symptoms of GERD until 2000. The examiner opined that it is less likely than not that the Veteran's current GERD is caused by or permanently worsened beyond its natural progression by the Veteran's PTSD. The examiner stated that the etiology of GERD is from acid reflux due to muscles in circular ring of lower esophageal sphincter which are weak or become relaxed because the stomach is distended; this allows liquids in stomach to wash back into esophagus. The examiner stated that this happens occasionally in all individuals. The examiner stated that the presence of a hiatus hernia makes symptomatic acid reflux more likely, as seen in this Veteran, and that the presence of hiatal hernia increases with age and obesity. Other VA medical records indicate that in August 2013, the Veteran was 70 inches tall and weighed 216 pounds; in May 2014 he weighed 221 pounds, and in September 2014 he weighed 222 pounds. (VA medical nutrition therapy note for high cholesterol and weight management dated September 8, 2014). The December 2014 VA examiner noted that the hiatus hernia shown in 2004 makes symptomatic reflux more likely. The examiner explained that a hiatal hernia is an anatomical finding that is not due to anxiety or PTSD, and that there is no indication that PTSD is a causative factor or risk factor for GERD in multiple comprehensive bodies of medical literature. The examiner opined that it is less likely than not that Veteran's GERD is permanently worsened beyond its natural progression by his PTSD. The examiner stated that the Veteran's GERD symptoms have remained essentially the same from the late 2000s until the present, and he does not take routine medication for the PTSD, noting in 2013 the Veteran stopped taking medication regularly because the Citalopram "makes him sleepy." The examiner noted that the Veteran did not report any worsening of GI symptoms due to more difficulty or flares of his PTSD, and instead reported continuous symptoms and nighttime symptoms. The examiner explained that well established and commonly accepted medical literature does not indicate a causal relationship between PTSD and GERD. During the January 2019 VA examination, the examiner noted that the Veteran has had diagnoses of GI conditions since January 2008, which include the following: episodic GI bleeding, due to recently diagnosed jejunal stromal tumor--spindle cell type; GERD; small hiatal hernia; mild distal/low grade esophagitis; erythematous duodenopathy; gastropathy; gastritis; and colon polyp. The examiner noted that the Veteran has had recurrent GI bleeds for years. A 2018 CT scan showed a small bowel mass, and a two to three-centimeter exophytic jejunal tumor was removed via segmental small bowel resection in November 2018. The examiner noted that the initial pathology report favored a benign stromal tumor; however, slides were sent to University of Nebraska for review. The examiner noted that this report is not in CPRS file or Vista Imaging, but apparently a malignant process was identified because the Veteran has been referred to oncology by his VA primary care physician. The examiner stated that the note for the January 16, 2019 visit is not yet in the VA treatment records; however, the primary care notes show that the last date GERD was discussed was October 2017. The examiner noted that the current VA medication list shows Dexlansoprazole, which is prescribed for stomach acid. The examiner opined that it is less than like that any of the GI conditions were incurred in-service or are otherwise related to the Veteran's service. The examiner stated that none of the GI conditions are due to old rations that were eaten during service, or due to exposure to the odor of decaying flesh during service. The examiner stated that prior VA examinations, particularly those from October 2012 and December 2014, have offered detailed rationales as to why the Veteran's GERD is not related to his service, and these rationales continue to hold true. The examiner stated that they also apply to the GERD-similar diagnoses of hiatal hernia, esophagitis, duodenopathy, gastropathy, and gastritis. The examiner noted that the Veteran did not report symptoms of any GI conditions in-service, none of the diagnoses were mentioned in the service treatment records, and there are no medical records that show the continuity of any of the GI conditions dating to service. The examiner stated that eating old rations and smelling decaying flesh does not cause any of the Veteran's GI conditions, and that stromal cell tumor is not caused by herbicide exposure or any other circumstances of the Veteran's service. An October 2020 private medical record shows that a review of the GI system was negative for hematochezia, melena, and ulcer disease. An April 2021 VA medical record indicates that the Veteran has a complicated history of signal intensity malignancy status post resection, which was noted to have occurred four to five years prior. The Veteran reported a history of umbilical hernia status post-surgery. However, the examiner noted that exact records of the Veteran's reported condition were not available for review. The examiner noted that the Veteran was negative for GI symptoms. As discussed above, the Veteran's service treatment records do not contain complaints, treatment, or diagnosis of any GI disorder, and the May 1970 report of medical examination at service separation shows a normal clinical evaluation of all systems, without any indication of any GI symptoms or disorder. The evidence shows that the Veteran has a history of GI bleeding since 1999. A November 2007 upper GI study shows a small sliding type hiatus hernia with GERD and low-grade esophagitis. The October 2012 examiner opined that it is less than likely that the Veteran's GERD is related to any in-service occurrence or event. The examiner noted that the service treatment records are silent of complaints or treatment for any GI disorder, that there are no medical records that show continuity of GERD symptoms dating to service, that the Veteran does not describe GERD symptoms on active duty, and that the first mention of GERD symptoms post-service are nearly 30 years after service. The December 2014 VA examiner noted that during the 2004 VA Agent Orange Registry examination, the only reported GI symptom was constipation. The examiner noted a current diagnosis of GERD, which was noted as the current etiology of the Veteran's GI disorders. The examiner opined that it is less likely than not that Veteran's GERD had its onset during or was caused by service. The examiner stated that the service treatment records do not show symptoms of or a diagnosis of GERD, and the separation examination is negative for the condition. The examiner stated that the etiology of GERD is from acid reflux due to muscles in circular ring of lower esophageal sphincter which are weak or become relaxed because the stomach is distended; this allows liquids in stomach to wash back into esophagus. The examiner stated that this happens occasionally in all individuals. The examiner stated that the presence of a hiatus hernia makes symptomatic acid reflux more likely, as seen in this Veteran, and that the presence of hiatal hernia increases with age and obesity. The January 2019 VA examiner opined that it is less than likely that any of the GI conditions were incurred in-service or are otherwise related to the Veteran's service. The examiner stated that none of the GI conditions are due to old rations that were eaten during service, or due to exposure to the odor of decaying flesh during service. The examiner noted that the Veteran did not report symptoms of any GI conditions while on active duty, none of the diagnoses were mentioned in the service treatment records, and there are no medical records that show continuity of any of the GI conditions dating to service. The examiner stated that eating old rations and smelling decaying flesh does not cause any of the Veteran's GI conditions, and that stromal cell tumors are not caused by herbicide exposure or any other circumstances of the Veteran's service. Service connection on a direct basis is not warranted. The probative medical evidence of record does not show that the Veteran's GI condition is directly related to his service, to include due to consumption of outdated rations while in Vietnam and while near the odor of decaying human flesh. Instead, the probative medical evidence of record shows that the Veteran was first diagnosed with GI bleeding in 1999. The probative medical opinions of record all show that the Veteran's GI condition is less likely than not related to his service, to include due to consumption of outdated rations while in Vietnam and while near the odor of decaying human flesh. There is no probative medical opinion of record that shows that the Veteran's GI condition is directly related to his service, include due to consumption of outdated rations while in Vietnam and while near the odor of decaying human flesh. Therefore, service connection for a GI condition is not warranted on a direct basis. See 38 U.S.C. §§ 1110. As discussed above, the Veteran is service-connected for PTSD, and the Veteran has several diagnosed GI conditions dating back to 1999. However, the probative medical opinions of record show that the Veteran's condition is not secondarily related to the service-connected PTSD. As the Veteran does not contend that his GI condition is secondarily related to any other service-connected disability, any further analysis of service connection on a secondary basis is not necessary. Therefore, service connection on a secondary basis is not warranted. See 38 C.F.R. § 3.310(a). Service connection for a GI condition, as secondary to service-connected PTSD, is not warranted. Although the record shows that the Veteran has a GI condition and is service-connected for PTSD, there is no probative medical opinion which relates the Veteran's GI condition to his service-connected PTSD. Therefore, the third element of service connection on a secondary basis is not met, and the claim must be denied. 38 C.F.R. § 3.310(a). While the Veteran believes that his condition is related to his service, he is not competent to establish a nexus between his current condition and his service. The issue is medically complex, as it requires specialized medical knowledge. Therefore, it is outside the competence of the Veteran because the record does not show that he has the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). To the extent that the Veteran contends that service connection is warranted based on continuity of symptomatology, post-service medical records show that the Veteran was first diagnosed with GI bleeding in 1999. There is no medical evidence of record that shows that any GI condition has been ongoing since his service. Therefore, service connection based on a continuity of symptomatology is not warranted. In conclusion, the claim of entitlement to service connection for a GI condition, due to consumption of outdated rations while in Vietnam and while near the odor of decaying human flesh, and as secondarily related to service-connected PTSD is denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. 38 U.S.C. § § 5107(b); 38 C.F.R. § § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). For these reasons, the claim is denied. 5. Service connection for a TBI is denied. The Veteran contends that he has a TBI that is related to an in-service accident when rocket detonated nearby, causing him fall onto his back. While the Veteran's account of in-combat experiences is presumed credible, the Veteran has not been diagnosed with TBI and has not had one at any time during the pendency of the claim or recent to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). The appeal will be denied. A February 2002 MRI of the brain related to the Veteran's right hand action tremor does not indicate the presence of a brain injury. The Veteran's service treatment records do not contain any complaints, treatment, or diagnosis of any brain injury, and the May 1970 report of medical examination at service separation shows a normal clinical evaluation of the head and neurologic system. There is no indication of any brain injury. During the June 2013 VA examination, the examiner noted that the Veteran does not now have nor has he ever had a TBI or residuals of a TBI. The Veteran reported that he was in Vietnam when a rocket blew up in front of him and pushed him backwards onto his radio and crushed his M16 and magazines. The Veteran reported that he thinks that he may have been knocked out. The examiner noted that the Veteran did not report feeling stunned, dazed, or having had headaches; however, the Veteran reported that he felt "angry." The Veteran reported that he did not seek any immediate post-service treatment. He reported that he was employed with the railroad for 17 years without any work-related concerns by his employer or himself. However, he reported that he occasionally gets lost while driving, which he associated with "daydreaming." The examiner noted that the Veteran was hospitalized for malaria in-service in November 1969 when he presented with fever and frontal headache, which the examiner noted is in a different location than is currently reported. The Veteran reported a history of numerous brain concussions in the past. The examiner noted that at the time of his in-service hospitalization, the Veteran reported occasional dizziness and staring. The examiner noted that the EEG and skull x-ray were both negative. The examiner noted that the May 1970 separation examination was negative for head injury/TBI, shrapnel wounds, persistent headache, or dizziness. The examiner also noted that sporadic private medical records between 2001 and 2007 were all negative for head injury/TBI, headache, dizziness, and imbalance. The examiner noted that the Veteran was evaluated for headache in January 2011, but that a CT scan of the head was negative. The examiner noted that during the 2004 Agent Orange Registry examination, the Veteran denied a history of accidents or TBI, but reported bitemporal headaches radiating to the neck; a diagnosis of muscle tension headaches was indicated. The examiner noted that the Veteran was evaluated by his primary care physician in March 2013 for depression, headaches, tremors, memory loss, PTSD, and TBI. The examiner opined that the Veteran's condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner stated that the reported daily headaches starting at the base of neck, radiating upward, clearly describe tension headaches. The examiner noted that the current headaches are not in the same location as when the Veteran was treated in-service, and that the headache reported during treatment for malaria in-service resolved and was more than likely related to his fever. The examiner noted that the separation examination is negative for headaches. The examiner noted that sporadic post-service treatment is negative for headaches until 2004 when the Veteran was diagnosed with tension headaches. The examiner noted that no dizziness condition is shown in the record, per the history reported by the Veteran, or on examination. During the November 2015 VA examination, the Veteran reiterated he was near a grenade explosion in-service in Vietnam when he was injured by shrapnel. The Veteran denied that he ever lost consciousness. The Veteran reported current headaches that start at his temples and feel like pressure. He also reported mood swings and irritability since his service. The examiner noted that the Veteran reported vague symptoms of being unable to remember things and being unable to care for himself. The examiner observed that the Veteran's symptoms have not prevented him from obtaining work, and the Veteran was relating cognitive symptoms with irritability symptoms of his PTSD. The examiner noted that the Veteran complained of photophobia and that he wore sunglasses to the examination. However, the Veteran did not identify the cause of the photophobia. The examiner also noted that the Veteran gave a non-descript post-service history of being dizzy off and on and stated that he sometimes must catch his balance when he is working around the trains as a railroad conductor. However, the Veteran reported that he has not fallen, has not been sent home, and is able to complete his shifts. The examiner opined that it is less than likely that the Veteran has any TBI or residuals thereof, to include headaches, balance problems, dizziness, decreased cognitive function, or other symptoms that was incurred in-service or caused by combat operations while in Vietnam. The examiner stated that the service and post-service history provided by the Veteran does not support the diagnosis of a TBI, and his medical records do not support the diagnosis of a TBI during his service. During the January 2019 VA examination, the examiner opined that it is less than likely that the Veteran had an in-service TBI, and it is less than likely that any in-service incident, including the Veteran's report of being knocked onto his back by a rocket explosion, resulted in a TBI. The examiner noted that detailed histories obtained from the Veteran at the time of the June 2013 and November 2016 VA examinations do not indicate that any TBI occurred, and both examiners concluded that the Veteran did not have an in-service TBI. The examiner noted that the Veteran was unable to describe any details of any incidents that were consistent with a TBI. The examiner explained that typically, when veterans describe a TBI, they provide precise details as to the last thing they remember before the event, as well as specific details and/or memories after the event. The examiner noted that the Veteran did not provide any such details of the event that would indicate that a TBI occurred. The examiner stated that loss or alteration of consciousness is necessary to establish the diagnosis of a TBI, and these were not described by the Veteran during any of the VA examinations. The examiner noted that the June 2013 VA examination lists several records where TBI and/or head injury had been denied by the Veteran. The examiner also noted that the service treatment records, including the separation examination, are silent for head injury and/or TBI. As discussed above, VA treatment records and examinations do not contain a diagnosis of a TBI. A February 2002 MRI of the brain does not indicate the presence of a brain injury. The June 2013 VA examiner noted that the Veteran does not now have nor has he ever had a TBI or residuals of a TBI. The examiner stated that reported daily headaches, starting at the base of neck, radiating upward, clearly describe tension headaches. The examiner also noted that sporadic private medical records between 2001 and 2007 were all negative for head injury/TBI, headache, dizziness, and imbalance. The examiner noted that the Veteran was evaluated for headache in January 2011, but that a CT scan of the head was negative. The examiner noted that during the 2004 Agent Orange Registry examination, the Veteran denied a history of accidents or a TBI. The November 2015 VA examiner stated that the history provided by the Veteran of his service and post-service does not support the diagnosis of TBI, and his medical records do not support the diagnosis of a TBI during his service. The January 2019 examiner noted that the Veteran was unable to describe any details of any incidents that were consistent with a TBI. Therefore, the preponderance of the evidence of record is against finding that the Veteran has had a diagnosis of a TBI at any time during or approximate to the pendency of the claim. While the Veteran believes that he has a diagnosis of a TBI or residuals thereof, he is not competent to provide a diagnosis in this case. The issue is medically complex, as it requires specialized medical education and knowledge of the interaction between multiple organ systems in the body. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence and the claim is denied. 6. Service connection for hypertension, as secondary to service-connected disabilities, is denied. The Veteran contends that he has hypertension that is solely related to his service-connected disabilities. The preponderance of the evidence is against the claim and service connection for hypertension is denied. The Veteran's service-connected disabilities include the following: PTSD, tinnitus, diabetes mellitus, type II, malaria, left ear hearing loss, and multiple shell fragment wounds. A July 2004 VA medical record shows a blood pressure reading of 142/92. The Veteran reported that he was recently told by his physician that his blood pressure was fine. The examiner noted that this is a single reading of hypertension, and that the Veteran needs three readings to get an average to see if he has hypertension. A June 2009 VA medical record shows a blood pressure reading of 128/94. A May 2014 VA medical record shows a blood pressure reading of 158/96; the assessment was hypertension. The Veteran's service treatment records do not show symptoms or a diagnosis of hypertension, and the May 1970 report of medical examination at service separation shows a normal clinical evaluation of the heart and vascular system. The Veteran's blood pressure was recorded as 120/80. During the November 2015 VA examination, the examiner noted that the Veteran's medical records are negative for hypertension. The examiner noted that the Veteran was erroneously diagnosed with hypertension in a May 2007 VA treatment record; his blood pressure was 135/77 at the time. The examiner noted that although the Veteran was on a beta-blocking medication, he was using the medication to treat tremors, not hypertension. The examiner noted that a March 2009 medical record shows a blood pressure reading of 128/94, which is an isolated elevated reading. The examiner also noted a May 2014 VA medical record shows a diagnosis of hypertension, which was based a blood pressure reading of 158/96. However, the examiner noted that the diagnosis was based on a single blood pressure reading. The examiner observed that the Veteran's hypertension is not clearly identified and it less likely than not proximately due to or the result of the Veteran's service-connected conditions. The examiner stated that a diagnosis of hypertension is based upon an average of two or more blood pressure readings, not taken on same day. The examiner stated that the Veteran was erroneously diagnosed on two separate occasions several years apart based only on one blood pressure reading. The examiner noted that the Veteran's medical records clearly document that he uses a beta-blocker for tremors. The examiner stated that the medical literature shows that, Citalopram, taken for PTSD, can lower blood pressure, and it does not cause high blood pressure or hypertension. The examiner stated that the issue of aggravation not applicable since hypertension is not identified. In a July 2020 VA medical note, the examiner stated that it is not clear that the Veteran has hypertension. In fact, the Veteran reported that he did not have hypertension in the past. An October 2020 private medical record shows a diagnosis of essential hypertension. A blood pressure reading was recorded as 110/70. In the October 2020 VA medical opinion, the examiner opined that the Veteran's claimed hypertension condition is less likely than not proximately due to or the result of his service-connected disabilities. The examiner stated that the records do not definitively substantiate a diagnosis and treatment history specifically for hypertension. The examiner concluded that since there is no definitive diagnosis of hypertension, the condition cannot be secondary to any of the Veteran's service-connected disabilities. The examiner opined that the same medical opinion and rationale for secondary service connection holds true for aggravation as well; the Veteran's claimed hypertension condition cannot be aggravated by the Veteran's service-connected conditions, as the evidence does not substantiate a diagnosis and treatment history specifically for hypertension. March 2021 VA medical opinions show that the examiner noted that the Veteran's medical records contain a diagnosis of hypertension. However, the examiner stated that the legitimacy of the diagnosis is debated in the medical record. The examiner noted that the record shows that two examiners diagnosed hypertension; however, the examiner stated that the diagnosis was erroneous, because the evidence does not support a diagnosis of hypertension. The examiner noted that the Veteran uses Propranolol, which could be used to treat hypertension, but that the Veteran uses the medication to treat his hand tremor. The examiner opined that the Veteran does not have hypertension and, even if the Veteran does have hypertension, it is less likely than not aggravated beyond its normal progression by his service-connected disabilities. An April 2021 VA medical record shows essential hypertension listed as an active problem. As discussed above, the Veteran has several service-connected disabilities, and the medical record contains indications that the Veteran has a diagnosis of hypertension. However, the most probative medical opinions of record are highly persuasive of the fact that the Veteran does not have a diagnosis of hypertension. Instead, the most probative medical evidence of record shows that the Veteran has had only isolated, elevated blood pressure readings. As the most probative medical evidence of record shows that the Veteran does not have a diagnosis of hypertension, any further analysis of service connection on a secondary basis is not necessary. Therefore, service connection on a secondary basis is not warranted. See 38 C.F.R. § 3.310(a). Service connection for hypertension, as secondary to service-connected disabilities, is not warranted. The Veteran's VA and private medical records are conflicting on the issue of whether the Veteran has a diagnosis of hypertension. However, the VA medical opinions of record are highly probative as to whether the Veteran has a diagnosis of hypertension. The VA opinions agree that, although the Veteran's medical records show elevated blood pressure readings at times, the elevated readings are sporadic and do not definitively substantiate a diagnosis hypertension. In fact, the July 2020 VA medical note shows that the Veteran denied having had hypertension in the past. While the record shows that the Veteran's uses medication that can be prescribed to treat hypertension, the record also shows that the medication has been prescribed to treat his tremor condition. Although the Veteran has service-connected disabilities, the probative medical opinions of record show that the Veteran does not have a diagnosis of hypertension. Therefore, the second element of service connection on a secondary basis is not met, and the claim must be denied. 38 C.F.R. § 3.310(a). Even if a diagnosis of hypertension was found, the probative medical evidence of record shows that any potential diagnosis of hypertension is not related to the Veteran's service-connected disabilities, to include any potential relationship to medications used to treat his service-connected disabilities. Therefore, even if the presence of a diagnosis of hypertension was to be conceded, the third element of service connection on a secondary basis would not have been met, and the claim would still be denied. 38 C.F.R. § 3.310(a). While the Veteran believes that he has hypertension that is related to his service-connected disabilities, he is not competent to diagnose the condition or to establish a nexus between his condition and any of his service-connected disabilities. The issue is medically complex, as it requires specialized medical knowledge. Therefore, it is outside the competence of the Veteran because the record does not show that he has the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). In conclusion, the claim of entitlement to service connection for hypertension, due to service-connected disabilities, is denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. 38 U.S.C. § § 5107(b); 38 C.F.R. § § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). For these reasons, the claim is denied. 7. Service connection for tremors of the hands, to include as due to herbicide exposure and/or secondary to service-connected malaria and/or PTSD, is denied. The Veteran contends that his bilateral hand tremor is related to his service, to include as due to being knocked onto his back after a nearby rocket explosion and/or exposure to concussive forces and/or herbicide agent exposure and/or secondarily related to service-connected malaria and/or PTSD. The preponderance of the evidence is against the claim and the appeal will be denied. A February 2002 private medical record shows a history of right-hand action tremor. MRI results show a normal study. The etiology of the reported tremor was noted as not evident. A July 2004 private medical letter from Dr. R.L.C. states that the Veteran has intention tremors of the bilateral hand. The examiner's stated belief was that the condition is related to the Veteran's service in Vietnam. This opinion is of low probative value since the examiner appears to have based the opinion entirely on the Veteran's report that his tremors onset in-service. The Veteran's service records were not discussed. Other than the examiner's stated belief that the condition is related to the Veteran's service, based on the Veteran's report, the opinion provides no other detail as to how the opinion was reached. Therefore, the opinion is of low probative value. Prejean, 13 Vet. App. at 444. In a January 2007 VA medical note, the examiner stated that the Veteran has tremors, apparently related to PTSD. This statement is of no probative value because the opinion is too speculative to establish a medical nexus. Polovick v. Shinseki, 23 Vet. App. 48 (2009). The Veteran's service treatment records do not contain any complaints, treatment, or diagnosis of any tremor condition, and the May 1970 report of medical examination at service separation shows a normal clinical evaluation of all systems evaluated, without any indication that any tremor condition was present at the time. A March 2005 VA examiner opined that the bilateral hand tremors are not related to service or aggravated by service-connected malaria. The examiner noted that, after a review of the Veteran's medical records and a review of the medical literature, there is no information that supports that hand tremors are a sequela of malaria. During the October 2012 VA examination, the examiner noted a diagnosis of essential tremor of the bilateral hand. The Veteran reported a long history of his hands shaking when writing and difficulty with writing. The Veteran reported that the condition is constant. The Veteran did not mention that his PTSD caused his bilateral hand tremor to worsen but reported that his entire body with shake if his PTSD is bothering him. The Veteran reported that his first post-service treatment was 15 or 16 years previously but reported that he noticed that his hands would shake when eating with utensils in Vietnam. The examiner opined that it is less than likely that the Veteran's essential tremor of the hands is related to his service. The examiner noted that the service treatment records are silent for any tremor condition and post-service medical records show treatment since approximately 1997, which is over 25 years after his service. The examiner opined that it is less than likely that the tremor is related to, caused by, or aggravated by the Veteran's service-connected PTSD. The examiner stated that the medical literature does not list PTSD as a causative or aggravating factor in essential tremor, and no mental health treatment records discuss PTSD-related issues causing or aggravating tremor. The examiner noted that the medical records show that medications prescribed for PTSD/depression did not cause or aggravate the tremor, and that the Veteran is not currently on medication for PTSD, yet the tremor persists and is reported to be worsening. The examiner explained that this indicates a lack of correlation between medications for PTSD and the tremor. The examiner stated that although the Veteran reported that his whole-body shakes when his PTSD is aggravated, he did not report that the tremor flares up when the PTSD flares up. The examiner stated that although emotions can temporarily aggravate essential tremor, this is not a permanent aggravation beyond the natural progression. The examiner also noted that the medical literature does not show a medically established association between PTSD and essential tremor. During the December 2014 VA examination, the examiner noted that the Veteran has a diagnosis of essential tremor. The examiner noted that there are no records prior to 2002 to support medical documentation of tremor. The examiner noted that the Veteran reported a history of tremor since 1970 during the Agent Orange registry examination in 2004; no neurological deficits on the examination and the Veteran was without significant tremor on examination. The examiner noted that a 2011 CT scan of the head and brain was negative. The examiner noted that a February 2011 VA neurology note shows no cogwheel or other rigidity, and the examiner stated that the Veteran has a slight fine resting tremor of the right upper extremity while at rest, but the tremor is most prominent when the Veteran writes and is less prominent when he mimics eating. The examiner noted that the current examination reveals the same symptoms as those noted in the February 2011 VA neurology note. The examiner noted that the Veteran has treated his condition with Propanolol since 2007. The examiner noted that the June 2013 VA examination was negative for a diagnosis of TBI, but mild tremor to hands was noted when asked to draw a picture. The examiner noted that the examination findings were negative for neurologic deficits secondary to a TBI, including the Veteran's reports of being knocked onto his back when a rocket exploded nearby. The examiner noted that the Veteran reported that he was on the ground most of time and was exposed to Agent Orange on a nearly daily basis in Vietnam, and that he first noticed some tremors in his hands during the mid-portion of his time in Vietnam when using utensils to eat. The examiner opined that it is less likely than not that the Veteran's hand tremor had onset during, or was caused by the Veteran's service, including exposure to Agent Orange, and it is less likely than not that Veteran's hand tremors would result from his being knocked onto his back when a rocket exploded nearby, or from being exposed to concussive forces. The examiner noted that the service treatment records are silent for tremor, and that the separation examination is negative for tremor or neurologic abnormalities. The examiner also noted that there are no records that document tremor soon after separating from service. The examiner noted that a letter from Dr. A., who treated Veteran's single relapse of malaria in October 1970, does not show tremor or neurologic issues. The examiner noted that the application for service connection for malaria in 1973 was three years post-separation and does not document any condition such as tremor, and there are no medical records to show any examination with evidence of tremor dating to service. The examiner noted that the first documentation of tremor was in 2002, when the Veteran reported that he had the condition for four to five years. The examiner also noted that the 2002 brain MRI was normal. The examiner observed that medical literature does not show trauma to cause or aggravate an essential tremor, and no chronic neurological diagnosis associated with trauma or blasts were found during the June 2013 VA TBI examination. The examiner noted that The Institute of Medicine of the National Academies resource, "Veterans and Agent Orange," does not list essential tremor to be associated with Agent Orange, and the toxicology profile for Agent Orange at the Center for Disease Control's Agency for Toxic Substances and Disease Registry does not report essential-type tremors as a consequence of Agent Orange exposure. The examiner opined that it is less likely than not that Veteran's hand tremor disorder is caused by, or permanently aggravated beyond natural progression by the Veteran's service-connected malaria. The examiner also found that medical literature does not support an association or causality of hand tremor disorder as a sequela of malaria. The examiner noted that the Veteran has not had signs or symptoms of recurrent malaria, to include fever and chills, since he was treated in 1971. The examiner noted that the Veteran was treated for malaria with the drug, Quinine, which does not cause any adverse neurological manifestations according to the medical literature. The examiner noted that the most severe type of plasmodium falciparum malaria is cerebral malaria, which implies neurocognitive changes, typically seizures and/or coma; it can also be associated with severe anemia, renal failure/acidosis, requiring hemodialysis. The examiner noted that the Veteran had a case of plasmodium falciparum malaria, and although it had one recurrence, it was not consistent with a case of severe or cerebral malaria. The examiner stated that the medical literature shows that chronic complications of malaria include hyperreactive malarial splenomegaly with associated anemia and some degree of pancytopenia. The examiner noted that the Veteran's complete blood counts in 2013 and 2014 are unremarkable for these findings. The examiner stated that a small proportion of patients develop nephrotic syndrome; however, this is not seen in the Veteran; he has normal urinalyses, no peripheral edema, or hypoalbuminemia. The examiner also opined that it is less likely than not that Veteran's hand tremor disorder is caused by, due to, or aggravated by his service-connected PTSD. The examiner noted that the Veteran's hand tremor is an essential tremor. The examiner stated that the medical literature shows that PTSD is not listed as a causative or aggravating factor for essential tremor. The examiner noted that the Veteran's medical records do not show physical examination findings that document the he has permanent aggravation of his essential tremor due to his PTSD. The examiner stated that tremors can be exacerbated by emotional stress, this phenomenon is transient and does not constitute a permanent aggravation beyond natural progression. The examiner stated that the Veteran does not report that any PTSD flares have led to permanent aggravation of his tremor. The examiner stated that the natural progression of essential tremor is to worsen over time, and that any worsening of the Veteran's tremor is consistent with natural progression. The examiner indicated that the medical literature is not in approximate balance with the January 2007 VA outpatient note that stated that the Veteran's tremor was apparently related to PTSD, and instead noted that the statement is not supported by a review of the in-service treatment records, post-service treatment records, or the medical literature. The examiner stated that the medical literature relied upon in the opinions provided are internationally accepted, and authoritative medical references. As the Veteran's tremor condition is not a disease in 38 C.F.R. § 3.309(e), presumptive service connection for the tremor condition due to herbicide agent exposure is not warranted. However, the Veteran is not prevented from establishing service connection on a direct basis. Combee v. Brown, 34 F.3d 1039, 1042 (Fed Cir. 1994). As discussed above, the February 2002 post-service private medical record indicates that the Veteran has a history of hand tremor, and the Veteran has reported that he first noticed his hand tremor when using utensils to eat in Vietnam. However, the Veteran's service treatment records do not show any complaints, treatment, or diagnosis of any tremor condition, and a clinical evaluation of all systems at service separation was normal, absent of any indication that any tremor condition was present at the time. A July 2004 medical opinion stated that the Veteran's condition is related to his service. However, the opinion is of low probative value because it is entirely based on the Veteran's report of symptoms in-service and does not contain a discussion of his service records, or other medical records dating to his service. During the October 2012 VA examination, the Veteran reported that his first post-service treatment for tremors was in the late 1990s, but he noticed that his hands would shake when eating with utensils in Vietnam. The examiner opined that it is less than likely that the Veteran's essential tremor of the hands is related to his military service. The examiner noted that the service treatment records are silent for any tremor condition and post-service medical records show treatment since approximately 1997, over 25 years after his service. The December 2014 VA examiner opined that it is less likely than not that the Veteran's hand tremor had onset during, or was caused by his service, including exposure to Agent Orange, and it is less likely than not that Veteran's hand tremors would result from his being knocked onto his back when a rocket exploded nearby, or from being exposed to concussive forces. The examiner noted that the service treatment records are silent for tremor, and that the separation examination is negative for tremor or neurologic abnormalities. The examiner also noted that there are no records that document tremor soon after separating from service. The examiner stated that the medical literature does not show that essential-type tremors occur because of Agent Orange exposure. Service connection on a direct basis is not warranted. The probative medical evidence of record does not show that the Veteran's tremor condition is directly related to his service, to include the result of a fall due to a rocket explosion, exposure to concussive forces, or herbicide exposure. Instead, the probative medical evidence of record shows that the Veteran was first diagnosed with hand tremor in the late 1990s, at the earliest. The probative medical opinions of record all show that the Veteran's tremor condition is less likely than not related to his service, to include the result of a fall due to a rocket explosion, exposure to concussive forces, or herbicide exposure. There is no probative medical opinion of record that shows that the Veteran's tremor condition is directly related to his service, to include the result of a fall due to a rocket explosion, exposure to concussive forces, or to include herbicide exposure. Therefore, service connection for the tremor condition is not warranted on a direct basis. See 38 U.S.C. §§ 1110. The Veteran contends that his tremor condition is secondarily related to his service-connected malaria and/or PTSD. However, the probative medical opinions of record do not show that the Veteran's tremor condition is related to his service-connected malaria or PTSD. Although the January 2007 VA examiner stated that the Veteran has tremors, apparently related to PTSD, the opinion is too speculative to establish a medical nexus. The October 2012 VA examiner also opined that it is less than likely that the tremor is related to, caused, or aggravated by the Veteran's service-connected PTSD. The examiner stated that the medical literature does not list PTSD as a causative or aggravating factor in essential tremor, and no mental health treatment records discuss PTSD-related issues causing or aggravating tremor. The examiner noted that the medical records show that medications prescribed for PTSD/depression did not cause or aggravate the tremor, and that the Veteran is not currently on medication for PTSD, yet the tremor persists and is reported to be worsening. The examiner explained that this indicates a lack of correlation between medications for PTSD and the tremor. The examiner stated that although the Veteran reported that his whole-body shakes when his PTSD is aggravated, he did not report that the tremor flares up when the PTSD flares up. The examiner stated that although emotions can temporarily aggravate essential tremor, this is not a permanent aggravation beyond the natural progression. The examiner also noted that the medical literature does not show a medically established association between PTSD and essential tremor. The December 2014 VA examiner opined that it is less likely than not that Veteran's hand tremor disorder is caused by, due to, or aggravated by his service-connected PTSD. The examiner noted that the Veteran's hand tremor is an essential tremor. The examiner stated that the medical literature shows that PTSD is not listed as a causative or aggravating factor for essential tremor. The examiner noted that the Veteran's medical records do not show physical examination findings that document the he has permanent aggravation of his essential tremor due to his PTSD. The examiner stated that tremors can be exacerbated by emotional stress, which is transient and does not constitute a permanent aggravation beyond natural progression. The examiner stated that the Veteran does not report that any PTSD flares have led to permanent aggravation of his tremor. The examiner stated that the natural progression of essential tremor is to worsen over time, and that any worsening of the Veteran's tremor is consistent with natural progression. The examiner indicated that the medical literature is not in approximate balance with the January 2007 VA outpatient note that stated that the Veteran's tremor was apparently related to PTSD, and the statement is not supported by a review of the in-service treatment records, post-service treatment records, or the medical literature. The March 2005 VA examiner opined that the bilateral hand tremors are not related to nor aggravated by his service-connected malaria. The examiner noted that, after a review of the Veteran's medical records and a review of the medical literature, there is no information that supports that hand tremors are a sequela of malaria. The December 2014 VA examiner opined that it is less likely than not that Veteran's hand tremor disorder is caused by, or permanently aggravated beyond natural progression by the Veteran's service-connected malaria. The examiner stated that the medical literature does not support an association or causality of hand tremor disorder as a sequela of malaria. The examiner noted that the Veteran has not had signs or symptoms of recurrent malaria, to include fever and chills, since he was treated in 1971. The examiner noted that the Veteran was treated for malaria with the drug, Quinine, which does not cause any adverse neurological manifestations according to the medical literature. The examiner noted that the most severe type of plasmodium falciparum malaria is cerebral malaria, which implies neurocognitive changes, typically seizures and/or coma; it can also be associated with severe anemia, renal failure/acidosis, requiring hemodialysis. The examiner noted that the Veteran had a case of plasmodium falciparum malaria in-service, and although it had one recurrence, it was not consistent with a case of severe or cerebral malaria. The examiner stated that the medical literature shows chronic complications of malaria include hyperreactive malarial splenomegaly with associated anemia and some degree of pancytopenia. The examiner noted that the Veteran's complete blood counts in 2013 and 2014 are unremarkable for these findings. The examiner stated that a small proportion of patients develop nephrotic syndrome; however, this is not seen in the Veteran; he has normal urinalyses, no peripheral edema, or hypoalbuminemia. As discussed above, the Veteran's malaria and PTSD are service connected, and the Veteran has had a diagnosis of bilateral hand tremor since the late 1990s, at the earliest. However, the probative medical opinions of record show that the Veteran's condition is not secondarily related to the service-connected malaria or PTSD. As the Veteran does not contend that his bilateral hand tremor is secondarily related to any other service-connected disability, any further analysis of service connection on a secondary basis is not necessary. Therefore, service connection on a secondary basis is not warranted. See 38 C.F.R. § 3.310(a). Service connection for bilateral hand tremor, as secondary to service-connected malaria and/or PTSD, is not warranted. Although the record shows that the Veteran has bilateral hand tremor and is service-connected for malaria and PTSD, there is no probative medical opinion which relates the Veteran's bilateral hand tremor to either service-connected condition. Therefore, the third element of service connection on a secondary basis is not met, and the claim must be denied. 38 C.F.R. § 3.310(a). To the extent that the Veteran contends that service connection is warranted based on continuity of symptomatology, the Veteran's service treatment records and post-service medical records are silent regarding any tremor condition within one year of separation from service. Although the Veteran has reported that he first noticed a hand tremor in-service, the post-service medical records show a diagnosis of hand tremor in the late 1990s, at the earliest, which is outside of the one year window to grant service connection for a chronic disability on a presumptive basis. The record does not contain any competent probative medical evidence to support this contention. In the absence of a demonstration of continuity of symptomatology, the onset of the condition is too remote from service to be reasonably related to service. See Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). Therefore, service connection for the Veteran's tremor condition is not warranted on a presumptive basis for chronic diseases under 38 C.F.R. § § 3.307(a). Although the Veteran is competent to relay lay-observable symptoms, he is not competent to opine as to the etiology of his tremor condition, as this is a complex medical question beyond the knowledge of a layperson and he lacks the requisite medical expertise. See Layno v. Brown, 6 Vet. App. 465 (1994); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In conclusion, the claim of entitlement to service connection for bilateral hand tremor, to include as due to being knocked onto his back after a nearby rocket explosion, exposure to concussive forces, herbicide agent exposure, and as secondarily related to service-connected malaria, and/or PTSD is denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. 38 U.S.C. § § 5107(b); 38 C.F.R. § § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity resulting from disability. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. To evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). When the Veteran is requesting an increased rating for a service-connected disability, the present disability level is the primary concern and past medical reports do not take precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). However, the most recent examination is not necessarily and always controlling; rather, consideration is given not only to the evidence but to both the recency and adequacy of examinations. Powell v. West, 13 Vet. App. 31 (1999). Nevertheless, the Board acknowledges that the Veteran may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis below is therefore undertaken with consideration of the possibility that different "staged" ratings may be warranted for different time periods. 8. A compensable rating for residuals of malaria is denied. The Veteran contends that he has residuals of malaria that are worse than that which is contemplated by his current noncompensable rating. For the following reasons, a compensable rating for residuals of malaria is denied. Pursuant to Diagnostic Code 6304, a 100 percent rating for malaria is assigned when there is an active disease process. Relapses must be confirmed by the presence of malarial parasites in blood smears. Thereafter, malaria is to be rated on the basis of residuals such as liver or spleen damage under the appropriate system. During the December 2014 VA examination, the examiner noted that the Veteran had malaria in-service, had one relapse within a year after service separation, and has had no relapse since. The examiner noted that the Veteran has no recurrent history of fever of unknown origin. The examiner stated that the medical literature shows that the most severe type of plasmodium falciparum malaria is cerebral malaria, which implies neurocognitive changes, typically seizures and/or coma, which can associated with severe anemia, renal failure and acidosis requiring hemodialysis. The examiner noted that the Veteran's case of plasmodium falciparum malaria, although recurrent, was not classified as a case of cerebral malaria. The examiner stated that the medical literature shows that chronic complications of malaria include hyperreactive malarial splenomegaly with associated anemia and some degree of pancytopenia. The examiner noted that the Veteran's complete blood counts in 2013 and 2014 are unremarkable for these findings. The examiner stated that a small proportion of patients develop nephrotic syndrome, which is not seen in the Veteran; he has normal urinalyses, no peripheral edema, or hypoalbuminemia. During the April 2017 VA examination, the examiner noted that the Veteran had malaria in-service. The Veteran reported current constant throbbing headache from the back of his neck toward the temples, with nausea, but without vomiting. The Veteran reported sensitivity to light and that he wears sunglass everywhere. He reported difficulty sleeping, fatigue, loss of balance, and feeling upset with himself and others. The Veteran reported having had a stroke in 2016; however, the examiner noted that the medical records show that the Veteran had a transient ischemic attack (TIA). The examiner noted that the Veteran's reported symptoms are not residuals of his service-connected malaria. The examiner stated that the Veteran's headaches are tension-type headaches. The examiner stated that other than one relapse of malaria shortly after service separation, his medical records are negative for any other relapse or residuals associated with malaria. The examiner stated that all other reported symptoms are not related to the service-connected malaria and can be seen in those with erratic work schedules, PTSD, and TIA. During the January 2019 VA examination, the examiner noted that the April 2017 VA examination showed no active malaria or residuals of malaria. The examiner noted that treatment records since the April 2017 VA examination do not show any malaria symptoms or residuals. The examiner noted that during service, the Veteran was hospitalized for malaria in November and December 1969 when he was diagnosed with falciparum malaria and treated with Quinine Sulfate, Gantrisin, and Daraprim. The examiner noted that the separation examination does not mention malaria or any residuals. The examiner noted that the Veteran was treated with Quinine in 1970 following a relapse of malaria. The Veteran reported that he does not currently have malaria. However, the Veteran stated his belief that his bad memory is related to having had malaria. The examiner noted that the Veteran's current diagnosis is falciparum malaria, resolved without residuals. The examiner also noted that CBC testing was completed on the day of the examination. The examiner noted that the decrease in CBC values is not due to any residual of malaria, the decreased Hgb/Hct are due to the gastrointestinal bleed that he had recently. Aldolase was measured as 3.3 U/l (<=8.1). The peripheral blood smear for malaria was negative. The examiner stated that a review of recent treatment records does not show that any splenomegaly was identified in the abdominal CT scan in 2018. The examiner stated that the Veteran does not currently have active malaria and stated that the Veteran's medical history and current examination do not indicate any active malaria. The examiner also noted that laboratory testing does not show evidence of active malaria, and no symptoms of active malaria are present. The examiner noted that no other laboratory testing for malaria is indicated. Regarding residuals of the malaria treated in-service, the Veteran's complaint of trouble remembering names is not consistent with a residual of malaria. The examiner also noted that the service treatment records show that the Veteran did not have cerebral or severe malaria. The examiner stated that cognitive impairment is not identified in the medical literature as a residual of uncomplicated malaria. The examiner opined that the Veteran's cognitive complaints are more likely due to multiple factors such as depression, trouble sleeping, etc. The examiner noted that the Veteran was able to work until his later 60s, indicating that there are no cognitive residuals of malaria. Based on the evidence, the Veteran does not meet the criteria for a higher rating. Specifically, since the documented relapse in 1970, there is no evidence that the Veteran was ever hospitalized for a relapse of malaria, nor is there evidence that a relapse was confirmed by the presence of malarial parasites in blood smears. Additionally, there is no clinical evidence demonstrating either liver or spleen damage secondary to malaria, such that residuals of malaria could be rated under the appropriate system. There is no evidence of residuals affecting any other system of the body. While the Veteran is competent to report symptoms that he experiences, as noted above, the medical evidence shows that his reported symptoms are not related to malaria, or residuals thereof. As such, the reported symptoms do not constitute a residual affecting a system of the body or causing damage to any system to the body. Instead, the probative medical evidence of record consistently shows that the Veteran does not have active malaria, symptoms of active malaria, or residuals of malaria. In conclusion, the Veteran's symptoms more nearly approximate a noncompensable rating. Therefore, the Veteran's claim for a compensable rating for malaria is denied. REASONS FOR REMAND 1. The issue of a compensable rating for shell fragment wounds, to include a superficial scar on the right distal leg and right thumb, is remanded. 2. The issue of a rating higher than 50 percent for PTSD is remanded. 3. The issue of a TDIU is remanded. The matters are REMANDED for the following action: 1. BACKGROUND FOR THE RO ADJUDICATOR: The Veteran has reported that his service-connected scars and PTSD have worsened since his most recent VA examinations in June 2013. Therefore, new VA examinations are necessary to determine the current severity of the disabilities. The issue of a TDIU is part of the issues of increased ratings for scars and PTSD; that issue also must be remanded. As the issue of a TDIU may be impacted by adjudication of the remanded issues, the issue of a TDIU is inextricably intertwined with the remanded issues. Accordingly, the Board will remand the issue of a TDIU. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). THE REMAND DIRECTIVES FOLLOW. 2. Ensure that all outstanding VA and private treatment records are associated with the claims file. 3. Schedule the Veteran for a VA examination with an appropriate VA examiner regarding the current severity of the Veteran's shell fragment wounds, to include a superficial scar on the right distal leg and right thumb. All evidence and a copy of this remand will be made available to the examiner, who will acknowledge receipt and review of these materials. The examiner is asked to respond to the following: (a.) Assess the current severity of the Veteran's shell fragment wounds, to include a superficial scar on the right distal leg and right thumb. The examiner's attention is drawn to the following: * The June 2013 VA examination. * The Veteran has reported that his scar disability has worsened since his last VA examination. 4. Schedule the Veteran for a VA examination with an appropriate VA examiner regarding the current severity of the Veteran's PTSD. All evidence and a copy of this remand will be made available to the examiner, who will acknowledge receipt and review of these materials. The examiner is asked to respond to the following: (a.) Assess the current severity of the Veteran's PTSD. (b.) If the examiner determines that the Veteran's PTSD has worsened in severity, to the extent possible, provide an approximate timeframe of when any worsening onset. The examiner's attention is drawn to the following: * The June 2013 VA examination. * An April 2021 VA mental health note shows that the Veteran complained of severe anxiety and depression related to PTSD. He reported that he has a lot of anxiety and anger that is impacting his physical health and his relationships. The Veteran also stated that "I don't like being around people. I have problems in all my relationships, including with my own family. I have a lot of anger and I feel like I need to do something about it because it's effecting me physically." The examiner noted symptoms of severe anxiety and depression. A thorough explanation must be provided for the opinions rendered. If the examiner cannot provide the requested opinions without resorting to speculation, s/he should expressly indicate this and provide supporting rationale as to why the opinions cannot be made without resorting to speculation. The examiner is advised that by law, the mere statement that the claims folder was reviewed and/or the examiner has expertise is not sufficient to find the examination/opinion sufficient. 5. Review the claims file to ensure that the requested development is completed to the extent possible and arrange for any additional needed development. Then readjudicate the remanded issues, including the issue of entitlement to a TDIU. 6. Following the review and any additional development deemed necessary, re-adjudicate the claims. Should the claims not be granted in their entirety, issue an appropriate supplemental statement of the case (SSOC) and forward the claims to the Board for adjudication. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the United States Court of Appeals for Veterans Claims (Court) for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112. Vito A. Clementi Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Timothy T. Emmart The Board's action is binding only in this matter. The Board's decision and its remand for further development are not precedential or establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.