Citation Nr: 0209685 Decision Date: 08/12/02 Archive Date: 08/21/02 DOCKET NO. 93-24 166 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Seattle, Washington THE ISSUES 1. Entitlement to service connection for an allergy disability. 2. Entitlement to service connection for left arm neuropathy. 3. Entitlement to an increased evaluation for a gastrointestinal disability characterized as hepatitis, status-post laparotomy for bowel obstruction with abdominal adhesions, status-post cholecystectomy, history of septicemia/bacteremia secondary to bile duct infection, history of pancreatitis and pancytopenia, currently evaluated as 60 percent disabling. (The issue of entitlement to a total disability compensation rating based on individual unemployability (TDIU rating) will be the subject of a later decision). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD C. L. Wasser, Counsel INTRODUCTION The veteran served on active duty from August 1986 to August 1987. This case comes to the Board of Veterans' Appeals (Board) partly from a May 1991 RO decision which denied an increase in a 60 percent rating for a service-connected gastrointestinal disability, and partly from a June 1993 rating decision which denied service connection for allergies and left arm neuropathy, and denied entitlement to a TDIU rating. A personal hearing was held before an RO hearing officer in June 1992. In October 1995, the Board remanded the case to the RO for further evidentiary development. The case was returned to the Board, and in May 1997, the Board again remanded the case to the RO for further evidentiary development. The case was subsequently returned to the Board. The Board is undertaking additional development on the issue of entitlement to a TDIU rating pursuant to authority granted by 67 Fed. Reg. 3,099, 3,104 (Jan. 23, 2002) (to be codified at 38 C.F.R. § 19.9(a)(2)). When it is completed, the Board will provide notice of the development as required by Rule of Practice 903. (67 Fed. Reg. 3,099, 3,105 (Jan. 23, 2002) (to be codified at 38 C.F.R. § 20.903). After giving the notice and reviewing any response to the notice, the Board will prepare a separate decision addressing this issue. FINDINGS OF FACT 1. All of the evidence necessary for an equitable disposition of the claim has been obtained. 2. The veteran does not presently have an allergy disability or left arm neuropathy attributable to military service. 3. The veteran's service-connected gastrointestinal disability is currently manifested by mild hepatitis C, with no more than moderate liver damage and disabling recurrent episodes of gastrointestinal disturbance, fatigue, and mental depression, or daily fatigue, malaise, and anorexia, with substantial weight loss (or other evidence of malnutrition), and hepatomegaly, or: incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain) having a total duration of at least six weeks during the past 12-month period, but not occurring constantly. CONCLUSIONS OF LAW 1. The claimed allergy disability and left arm neuropathy were not incurred in or aggravated by service. 38 U.S.C.A. § 1131 (West 1991 & Supp. 2001); 38 C.F.R. § 3.303 (2001). 2. The criteria for a rating in excess of 60 percent for the service-connected gastrointestinal disability have not been met. 38 U.S.C.A. 1155 (West 1991 & Supp. 2001); 38 C.F.R. § 4.114, Diagnostic Code 7345 (2000), 38 C.F.R. § 4.114, Diagnostic Codes 7345, 7354 (2001). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board notes that during the pendency of this appeal, the Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000), was signed into law. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, and 5107 (West Supp. 2001). This liberalizing law is applicable to this appeal. See Karnas v. Derwinski, 1 Vet. App. 308, 312-13 (1991). To implement the provisions of the law, the VA promulgated regulations published at 66 Fed. Reg. 45,620 (Aug. 29, 2001) (to be codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a)). The VCAA and implementing regulations essentially provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. It also includes new notification provisions. Records identified by the veteran have been obtained, and the veteran has undergone several VA examinations. He and his representative have been notified of evidence required to substantiate the claims. Such notice is found in multiple requests for evidence, the rating decision, the statement of the case, letters to the veteran, and several supplemental statements of the case. The veteran has submitted voluminous medical records and written arguments. The Board concludes that the notice provisions of the VCAA and companion regulation have been satisfied in this case to the extent possible. Id. Although a requested VA social industrial survey has not yet been completed, the Board finds that this survey is not necessary to adjudicate the issues of entitlement to service connection for allergies, entitlement to service connection for left arm neuropathy, and entitlement to an increased rating for a gastrointestinal disability, as the survey was requested due to the veteran's claim for a TDIU rating. Based on the entire record, the Board finds that all relevant evidence has been developed to the extent possible, and the duty to assist provisions of the VCAA and implementing regulation have been satisfied. I. Factual Background The veteran served on active duty from August 1986 to August 1987. On medical examination performed for enlistment purposes in August 1985, his upper extremities were listed as normal. No allergies were noted. Service medical records include an October 1986 treatment note showing that the veteran was treated for complaints of numbness of the left arm and hand for the past two weeks. He said his sling was too tight at the rifle range. On examination, there was full range of motion without pain, slow opposition, and no neurological deficits. Grip strength was 5/5 on the right and 2/5 on the left. On pinprick testing, there were sensory deficits of the medial aspect of the left forearm and left hand. The diagnostic assessment was rule out nerve compression neuropathy of the left arm. Later that day, he was diagnosed with sling palsy; physical therapy was prescribed. A consultation report from the physical therapy department reflects a diagnosis of left upper extremity compression neuropathy. The veteran received physical therapy from October 1986 to December 1986. In early November 1986, the veteran complained of achy pain and bruising over the left biceps. It was noted that the veteran had been lifting weights. The diagnosis was compression neuropathy with neuritis. A November 1986 electromyography (EMG) showed evidence of denervation (acute changes) in the muscles of the medial, ulnar, radial nerves, and some minor evidence of renervation. On neurology consultation in November 1986, strength was 4/5 in the muscles of the left arm and hand. It was noted that a recent EMG was consistent with involvement of much of the lower brachial plexus. Continued physical therapy was recommended. A few days later, it was noted that the veteran continued to have significant weakness of the left hand and grip. He was returned to duty and restricted from rope climbing and rappelling. A December 1986 treatment note shows that the veteran was seen for follow-up of compression neuropathy of the left arm, which was significantly improving. There was full range of motion of the left arm and hand, which were neurovascularly intact. Grip strength was 5+/5, and there were no contractures. It was noted that the veteran had no known allergies. In January 1987, the veteran reported that he continued to note a gradual return of strength. He had no sensory complaints, neck pain, or shoulder pain. On examination, there was 5/5 strength in the left triceps, biceps, slight weakness in some of the other muscles of the left upper extremity, and 4+/5 strength of the intrinsics of the left hand. The diagnostic assessment was resolving left brachial plexopathy. Subsequent service medical records are negative for treatment of left arm neuropathy. Service medical records reveal extensive and lengthy treatment for gastrointestinal complaints, including persistent abdominal pain. The veteran was initially treated for varicella (chickenpox) in December 1986, then for varicella pneumonia and hemoptysis, then for hematemesis and decreased hematocrit. Studies revealed gastric erosions and duodenal inflammation with no active bleeding. He was given a transfusion of red blood cells. He developed gastrointestinal bleeds. Gastroscopy studies did not identify the source other than small gastric erosions and a possible anterior dysplastic lesion. A colonoscopy was normal. An exploratory laparotomy showed splenic flexure adhesions with no abscesses. A second exploratory laparotomy revealed multiple adhesions with no evidence of Crohn's disease, abscesses or other congenital abnormalities. An appendectomy was performed. In March 1987, an endoscopy showed a normal esophagus and ulcers and erythematous patches in the stomach. A March 1987 discharge summary notes that he had a lengthy hospital course and an as yet unresolved single diagnosis of prolonged episodes of heme positive stools and gastrointestinal bleeding. The discharge diagnoses were varicella (resolved), varicella pneumonia (resolved), gastrointestinal bleed secondary to gastric angiodysplasia, anemia probably secondary to bleed, polymicrobial bacteremia with possible early sepsis, hepatocellular disease, leukopenia secondary to Cleocin (clindamycin), thrombophlebitis of the right upper extremity, pneumothorax (resolving), and heart murmur and transient rub (resolved). He was transferred to another hospital. In May 1987, he underwent an exploratory laparotomy, with a lysis of adhesions. He was fed parenterally, and developed probable non-A non-B hepatitis (i.e. hepatitis C), although a hepatitis panel was negative. He was treated for pancreatitis, and he underwent a cholecystectomy to remove his non-functioning gallbladder. A Medical Board Report dated in August 1987 reflects that the veteran was diagnosed with acute cholelithiasis, gallstone pancreatitis, and chronic cholecystitis. He tolerated a regular diet without difficulty, and it was recommended that he be returned to full duty. An August 1987 Medical Board Report Cover Sheet reflects that the veteran was diagnosed with intra-abdominal adhesions with chronic bowel obstructions, secondary to previous laparotomy, central venous catheter sepsis, cholelithiasis, gall stone pancreatitis, and chronic cholecystitis. Private medical records dated from September 1987 to January 1988 from Kootenai Medical Center reflect treatment for gastrointestinal complaints. Records dated in September 1987 and December 1987 reflect that the veteran was allergic to Cleocin (clindamycin). A January 1988 outpatient report indicates that the veteran's allergies were "many". A January 1988 report of an addendum to previous Medical Board reports shows that the veteran was hospitalized for evaluation from late October 1987 to late November 1987. Multiple tests were performed. The discharge diagnoses were chronic abdominal pain of unclear etiology, episodic acute decreases in hematocrit of unknown etiology after an extensive work-up, history of varicella, complicated by varicella pneumonia, status post cholecystectomy, appendectomy, lysis of adhesions and laparotomies times three. A report of the physical evaluation board (PEB) dated in January 1988 shows that the veteran was found to be unfit for service due to physical disability. The PEB determined that the veteran's episodic pancytopenia of unclear etiology rendered him unfit. The following conditions were found to be contributing to the unfitting condition: intra-abdominal adhesions with chronic bowel obstructions, secondary to previous laparotomy, central venous catheter sepsis, cholelithiasis, gall stone pancreatitis, chronic cholecystitis, and episodic pancytopenia of unclear etiology. The PEB determined that the veteran's disabilities were 60 percent disabling. In a March 1988 rating decision, the RO established service connection for a gastrointestinal disability characterized as: intra-abdominal adhesions with chronic bowel obstructions secondary to previous laparotomy, cholelithiasis/cholecystitis, gall stone pancreatitis, and pancytopenia. A 60 percent rating was assigned for this disability, which has remained in effect to the present. Private medical records dated from April 1989 to May 1989 from Deaconess Medical Center reflect treatment for complaints of right upper quadrant pain, a drop in hematocrit levels, and sepsis. Private medical records dated from 1987 to 1989 reflect episodic treatment, including multiple hospitalizations, at Kootenai Medical Center and North Idaho Cancer Center, for intermittent abdominal pain, drops in hematocrit levels without evidence of bleeding, intermittent anemia, leukopenia, and thrombocytopenia. J. Bertram, M.D. attended to the veteran during these confinements. A January 1988 treatment note shows that the veteran presented with a complaint of blue hands; on examination, there were no neurological abnormalities. In February 1988, Dr. Bertram indicated that a physical examination was within normal limits. In a November 1988 discharge summary, Dr. Bertram indicated that he did not believe that the veteran had a hematological disorder, and stated that many tests had been performed at various times, and that none of the tests ever showed any abnormality. In a February 1989 discharge summary, Dr. Bertram noted that the causes of the veteran's abdominal pain had never been decided despite a very intensive work-up during multiple hospitalizations at different hospitals and treatment by different doctors. He indicated that as on earlier hospitalizations, the veteran's hematocrit level was normal on admission, but decreased rapidly within 24 hours by 10 points, which corresponded to approximately 3 units of blood. Tests were performed and there was no evidence of internal bleeding or blood in the stool. Dr. Bertram concluded that the veteran was performing blood-letting on himself, although no evidence of this had been found, and recommended psychiatric treatment. An April 1989 discharge summary shows that the veteran was treated for abdominal pain and septicemia with Klebsiella pneumoniae. Medical records from University of Virginia Medical Center dated in July 1988 reflect treatment for chronic abdominal pain of unknown etiology. An emergency services nursing assessment noted that the veteran was allergic to Compazine and Cleocin. In the discharge summary, the only allergy noted was to Cleocin. A November 1998 discharge summary from Virginia Mason Hospital shows that the veteran complained of right upper quadrant pain. The final diagnosis was abdominal pain of unknown etiology. The examiner indicated that "Virtually every disorder that can be ruled out has been ruled out." VA medical records dated from February to May 1989 reflect treatment for right upper quadrant abdominal pain of questionable etiology. A VA discharge summary shows that in October 1989, the veteran was treated for acute hepatitis B. October 1989 medical reports from Holy Family Hospital reflect treatment for complaints of abdominal pain. An abdominal ultrasound showed mild homogenous splenic enlargement. It was noted that the veteran had many allergies, including Compazine and Reglan. By a statement dated in March 1991, the veteran asserted that his service-connected disability was more disabling than currently evaluated. He reported treatment at Davis-Monthan Air Force Base (AFB) in Tucson, Arizona, and at the Spokane VA Medical Center (VAMC). The RO wrote to Davis-Monthan Air Force Base (AFB), and by a letter dated in April 1991, the base indicated that no records were on file. The RO wrote to the Spokane VAMC and requested a copy of treatment records dated from 1990 to the present; in April 1991 the Spokane VAMC responded, enclosing a copy of a single treatment record pertaining to a lump on the head. The VAMC indicated that no other treatment records were available. Medical records dated from 1991 to 1992 from Dr. Goodell, Sacred Heart Medical Center, and Deaconess Medical Center reflect treatment for complaints of abdominal pain and for elevated liver function tests. An esophagogastro- duodenoscopy showed proximal gastritis. A hepatobiliary scan was normal. Studies revealed no evidence of obstruction of the common duct, which was of normal size. The discharge summary shows that the veteran reported that he was allergic to medications normally used for anti-emesis, including Compazine, Reglan, Vistaril, and phenothiazines. Private medical records dated from 1991 to 1992 from Rockwood Clinic reflect treatment for a variety of conditions, including complaints of left hand paresthesias. A January 1992 treatment note shows that the veteran reportedly had no allergies, although other records noted allergies. In early March 1992, the veteran reported that during service he had rapid onset of left arm weakness and numbness after wearing a tight sling. The diagnosis was recurring hand paresthesias on the left. There was no clinical evidence of weakness although there was some give away weakness with poor effort of some muscle groups. "The original injury may well have been multiple arm neuropathies related to compression injury in the left proximal arm region." An EMG was performed a few days later, and was normal. The diagnosis was left hand paresthesias. The examiner opined that the veteran likely had intermittent ulnar compressive neuropathy at the left elbow that probably represented early cubital tunnel syndrome. Records show that the veteran was reportedly allergic to Cleocin, Reglan, Compazine, Vistaril, Cipro, and Darvocet. By a statement dated in March 1992, the veteran asserted that his service-connected gastrointestinal disability should be rated 100 percent disabling. He enclosed a list of his medical problems, including hepatitis C, hepatitis B, liver disorders, biliary disease, biliary dyskinesia, recurrent pancreatitis, abdominal adhesions, and chronic bacteremia and septicemia. He contended that since 1987, he had spent 431 days being treated in hospitals. The veteran stated that he was in constant pain or discomfort, and that due to his illness, he had lost jobs and was forced to withdraw from school. He also claimed service connection for neuropathy of the left arm and hand, and asserted that he was chronically allergic to many common medications. He contended that a doctor told him these allergies were caused by "mishandling" during military hospitalizations. He said he had no allergies prior to service, and that he was now allergic to Vistaril, Cleocin, Darvocet, Compazine, Reglan, Cipro, and all butyrophenones. He enclosed a detailed list of treatment dating from service through 1991. According to him, his post-service treatment primarily related to abdominal pain. In April 1992, the RO wrote to the medical providers identified by the veteran and requested copies of treatment records. At a June 1992 RO hearing, the veteran reiterated many of his assertions. He stated that he had recurrent gastrointestinal and liver problems, and recurrent pancreatitis, which was manifested by pain. He said he was often nauseated, and was allergic to most nausea medications. He stated that he was often tired, and often jaundiced. He said he had colon spasms which were visible to the naked eye. At a November 1992 VA general medical examination, the veteran reported a history of a nerve compression of the left forearm and hand, with continued improvement in his left arm since service. He said his grasp was weak in the left hand. He also reported numerous chronic allergies to drugs, including Cleocin, Compazine, Reglan, Vistaril, Darvocet, Halcion, Haldol, and all phenothiazide derivatives. His allergic symptoms reportedly included urticarial rashes, wheezing respiration, tongue swelling, and jaw locking. On examination of the left upper extremity, the biceps, triceps, and pronator reflexes were all equal and active, and hand function was normal in all respects. There was possible, very equivocal, slight atrophy of the hypothenar muscles on the left when compared to the right hand. The examiner stated that left grip strength was perhaps equivocally diminished when compared to the right side. Measurements of both forearms were equal bilaterally, and strength of the arm and forearm was normal. The neurological examination otherwise appeared within normal limits. The diagnoses were history of nerve damage to the left upper extremity because of a rifle strap injury with slight weakness of grasping ability of the left hand, and numerous allergies to medications. A November 1992 report of nerve conduction studies showed no evidence of left medial or ulnar neuropathy, but did show minimal residual of a previous left upper arm compressive neuropathy. The examiner indicated that there had been improvement since a 1986 study. At a March 1993 VA gastrointestinal examination, the veteran presented voluminous medical records for the examiner's review. He complained of discomfort in his epigastrium and right upper quadrant. This discomfort was not always aggravated by eating, nor was it associated with continuous nausea or vomiting. He described mostly normal stooling habits, although he had looser bowel movements. His weight had been gradually increasing over the past year. On examination, he was alert and oriented with no signs of chronic illness. His general examination was unremarkable. He weighed 194 pounds. His abdominal examination showed abdominal scars which were not herniated. There was no abdominal distention. By palpation, there was no enlargement of liver or spleen. There were no other abnormalities detected. Bowel sounds were normal, the rectal examination was unremarkable, and there were no signs of scleral icterus. The examiner opined that the veteran did not show evidence of malnutrition, and there was evidence of increasing weight with no evidence of debilitating chronic illness. The examiner summarized private medical records, and noted that recent X-ray studies of the upper gastrointestinal tract and small bowel were within normal limits with no signs of ulceration to suggest chronic partial bowel obstruction. The diagnoses were abdominal pain, nausea and vomiting, recurrent, etiology undetermined, status post hepatitis B, status post hepatitis C, with evidence of continuing hepatitis, history of recurrent pancreatitis with no evidence of recurrence, status post ampulla of vater papillotomy times two, status post cholecystectomy (for gallstones), and status post gastrointestinal hemorrhage, remote, no recurrence. The examiner stated that it did not seem reasonable to accept the diagnosis of abdominal adhesions to account for the veteran's chronic discomfort, but it was possible that irritable bowel syndrome was a tenable diagnosis. There were no current objective findings to suggest pancreatitis. Tests showed current hepatitis C. The examiner said that the relationship between the ongoing hepatitis and recurring abdominal symptoms was not clear, but that fatigue and poor response to physical exertion and activity could very well be the result of hepatitis C or B. A May 1993 temporary disability retirement evaluation from the service department summarized the veteran's extensive gastrointestinal medical history. It was noted that the veteran was allergic to multiple medications including Clindamycin, Compazine, Reglan, Vistaril, Darvocet, Halcion, and Haldol. A neurologic examination was intact to include upper extremity motor strength. The diagnoses were chronic abdominal pain, recurrent and of unclear etiology which has prevented him from holding jobs, working in school, and resulted in his Medical Board, episodes of decreased hematocrit and associated bacteremia of unclear etiology despite multiple evaluations, and history of cholecystectomy, appendectomy, lysis of adhesions and laparotomies for chronic abdominal pain, without clear pathology found at the time of these procedures. In a June 1993 rating decision, the RO recharacterized the veteran's service-connected gastrointestinal disability as hepatitis, status post laparotomy for bowel obstruction with abdominal adhesions, status post cholecystectomy, history of septicemia/bacteremia secondary to bile duct infection, history of pancreatitis and pancytopenia. A 60 percent rating was continued. By a statement dated in June 1993, the veteran stated that his records show that he had complications from allergies to medications dating back to service. In October 1995, the Board remanded the case to the RO for VA examinations to determine the nature and current severity of the veteran's gastrointestinal disability, to determine the etiology of the veteran's allergies, and to evaluate his claimed left arm disability. The RO was also asked to contact the veteran and ask him to identify current treatment providers. Private medical records dated from 1993 to 1998 reflect episodic treatment for abdominal pain of questionable etiology. By a letter to the veteran dated in June 1996, the RO asked him to provide names and addresses for health care providers who treated him for a gastrointestinal disability since 1992, and for allergies and a left arm disability since separation from service. He was also asked to identify the doctor who told him that his current allergies to medications were due to service. Unfortunately, this letter was sent to an incorrect address. In June 1996, the RO scheduled VA examinations to evaluate the veteran's service-connected gastrointestinal disability and his claimed left arm and allergy conditions. The veteran failed to report for such examinations. It appears that the notice of the examinations was sent to an incorrect address. By a statement dated in May 1997, the veteran's representative requested that the case be remanded to the RO for another attempt to schedule the veteran for VA examinations. In May 1997, the Board again remanded the case to the RO for VA examinations to determine the nature and current severity of the veteran's gastrointestinal disability, to determine the etiology of the veteran's allergies, and to evaluate his claimed left arm disability. The RO was also asked to contact the veteran and ask him to identify current treatment providers. By a letter to the veteran dated in July 1997 (sent to the veteran's then current address), the Washington, DC RO asked him to provide names and addresses for health care providers who treated him for a gastrointestinal disability since 1992, and for allergies and a left arm disability since separation from service. He was also asked to identify the doctor who told him that his current allergies to medications were due to service. VA examinations were scheduled for the veteran and later canceled when the veteran moved to another state. By a letter to the veteran dated in April 1998 (sent to the veteran's then current address), the Seattle, Washington RO asked him to provide names and addresses for health care providers who treated him for a gastrointestinal disability since 1992, and for allergies and a left arm disability since separation from service. He was also asked to identify the doctor who told him that his current allergies to medications were due to service. At an August 1998 VA general medical examination, the veteran complained of pain in his left arm. He denied treatment for a left arm disability since service. He complained of numbness and tingling of the little and ring fingers of his left hand which went halfway up his forearm. He said he did not believe he had significant weakness of his left arm or hand. The examiner noted that both of the veteran's hands were heavily calloused with clear signs of active use. The examiner indicated that there was no objective evidence of neuropathy or any neurologic condition of the upper extremities, and there was nothing that could be attributed to his past exposure in the military. He opined that it was possible that the veteran might have some of these symptoms from resting his elbow on objects, but there are certainly no signs now of a positive Tinel sign at the wrists or elbows. By a letter dated in November 1998, a surgical gastroenterologist, J. Sonneland, MD, indicated that he had examined the veteran on behalf of the VA in September 1998, to evaluate his service-connected gastrointestinal disability. He noted that he had reviewed the veteran's medical records, and provided a comprehensive summary of pertinent records dating from service to 1998. He said that the veteran had the following complaints (in the veteran's order of priority): right upper quadrant abdominal pain, fatigue, diarrhea, and nausea. The veteran said his pain was not aggravated by eating, but rather by walking. The veteran reported that he was allergic to Reglan, Compazine, Vistaril, Cleocin, Darvocet, Halcion, and Toradol. Dr. Sonneland noted that the medical history was replete with contradictions, tests and procedure duplications, numerous negative findings, and positive findings which were often unexplained. On examination, the veteran weighed 206 pounds. On abdominal examination, there were scars and no evidence of weakness. The liver, kidneys and spleen were not palpably enlarged. There was a slight report of tenderness in the right upper quadrant. The diagnoses were narcotic addiction, hepatitis C, chronic and mild, status post cholecystectomy, and status post appendectomy. Dr. Sonneland stated that the veteran appeared to be a vigorous and healthy young man, and noted that as early as 1988, doctors had questioned his symptomatology and his high tolerance of narcotic medications. He indicated that repeated liver enzyme studies and histologic studies suggested minimal hepatitis not requiring treatment. He stated that there had been no evidence of pancreatitis for many years, and said he could find nothing in the record to relate gastrointestinal symptomatology to a service-connected problem. In a March 1999 addendum, Dr. Sonneland indicated that there was nothing in the record which would substantiate a claim of chronic allergies resulting from medications taken for the veteran's gastrointestinal disease. He stated that most allergic problems related to the medicines identified by the veteran were transitory, and resolved in a matter of days. He opined that other long-term allergic problems known to be associated with these medications had not been shown in the veteran's case. Finally, he stated that the veteran had no objective findings in recent years to substantiate a diagnosis of gastrointestinal disease, whether or not associated with allergies. II. Analysis A. Entitlement to Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1131 (West Supp. 2001); 38 C.F.R. § 3.303 (2001). 1. Claimed Allergy Disability The veteran contends that as a result of "mishandling" during in-service hospitalizations, he currently has chronic allergies to many common medications. Service medical records show that the veteran received extensive treatment for a variety of conditions, primarily gastrointestinal, during his 1986-1987 period of active service. Service medical records show that the veteran developed leukopenia secondary to Cleocin (clindamycin, an antibiotic). Treatment with this medication was promptly discontinued. Service medical records are negative for a diagnosis of "chronic allergies", and no other medication allergies were diagnosed during service. Post-service medical records show that at times the veteran has no listed allergies, and at other times, he reports that he is allergic to several different medications, and doctors have transcribed his reported allergies. Although the veteran has asserted that a doctor told him these allergies were caused by "mishandling" during military hospitalizations, he has neither identified this doctor nor provided a medical opinion by such doctor to this effect, despite multiple opportunities to do so. There is no medical evidence in the file demonstrating that the veteran has current chronic allergies which are linked to service. Moreover, in March 1999, after conducting a comprehensive review of the veteran's medical records, Dr. Sonneland indicated that there was nothing in the record which would substantiate a claim of chronic allergies resulting from medications taken for the veteran's gastrointestinal disease. Although the veteran has asserted that he has chronic allergies due to in-service treatment, as a layman, he is not competent to render an opinion regarding diagnosis or etiology. Espiritu v. Derwinski, 2 Vet. App. 492 (1992). As there is no medical evidence in the file demonstrating that the veteran has current chronic allergies which are linked to service, the Board finds that the preponderance of the evidence is against the veteran's claim for service connection for allergies due to medication given to him in service. Consequently, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b) (West Supp. 2001); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. Left Arm Neuropathy The veteran contends that he currently has neuropathy of the left upper extremity due to an in-service injury. Service medical records from the veteran's 1986-1987 period of active service reflect that in October 1986, the veteran was treated for complaints of numbness of the left arm and hand. He was diagnosed with compression neuropathy of the left upper extremity. Service medical records show that he received physical therapy for this condition, which gradually improved. A November 1986 electromyography (EMG) showed evidence of denervation (acute changes) in the muscles of the medial, ulnar, radial nerves, and some minor evidence of renervation. The condition was noted to be resolving in January 1987, and subsequent service medical records are negative for the condition. Post-service medical records dated in March 1992 include an EMG that was normal. The examiner opined that the veteran likely had intermittent ulnar compressive neuropathy at the left elbow that probably represented early cubital tunnel syndrome. During a November 1992 VA general medical examination, the examiner diagnosed history of nerve damage to the left upper extremity because of a rifle strap injury with slight weakness of grasping ability of the left hand. A November 1992 report of nerve conduction studies showed no evidence of left medial or ulnar neuropathy, but did show minimal residual of a previous left upper arm compressive neuropathy. The examiner indicated that there had been improvement since a 1986 study. At an August 1998 VA general medical examination, there was no objective evidence of neuropathy or any neurologic condition of the upper extremities, and the examiner opined that there was nothing that could be attributed to his past exposure in the military. The Board finds that as there is no competent medical evidence of any currently diagnosed left arm neuropathy, there is no current disability for which service connection might be granted. See Degmetich v. Brown, 104 F.3d 1328 (1997). As the preponderance of the evidence is against the veteran's claim for service connection for left arm neuropathy. Consequently, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b) (West Supp. 2001); Gilbert, supra. C. Entitlement to an Increased Rating for a Service- Connected Gastrointestinal Disability The veteran contends that his service-connected gastrointestinal disability is more disabling than currently evaluated. He asserts that a 100 percent rating should be assigned for this disability. When rating the veteran's service-connected disability, the entire medical history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). However, the present level of disability is of primary concern in a claim for an increased rating; the more recent evidence is generally the most relevant in such a claim, as it provides the most accurate picture of the current severity of the disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A § 1155 (West 1991); 38 C.F.R. Part 4 (2000). The RO initially rated the veteran's service-connected gastrointestinal disability under 38 C.F.R. § 4.117, Diagnostic Code 7700, pertaining to anemia. In June 1993, the RO recharacterized the disability, and evaluated it under 38 C.F.R. § 4.114, Diagnostic Code 7345, pertaining to infectious hepatitis. In this regard, the Board notes that when an unlisted condition is encountered it is permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20 (2001). The disability is now characterized as hepatitis, status post laparotomy for bowel obstruction with abdominal adhesions, status post cholecystectomy, history of septicemia/bacteremia secondary to bile duct infection, history of pancreatitis and pancytopenia. The veteran's only current diagnosed gastrointestinal disability is hepatitis. During the course of this appeal, the rating criteria for liver disorders were changed effective July 2, 2001. As the veteran's claim for an increased rating for a gastrointestinal disability was pending when the regulations pertaining to liver disorders were revised, he is entitled to the version of the law most favorable to him. Karnas v. Derwinski, 1 Vet. App. 308 (1990). Here, either the prior rating criteria or the revised rating criteria may apply, whichever are most favorable to the veteran. Although the RO issued an supplemental statement of the case to the veteran in February 2002, they only included the prior version of Code 7345. The Board finds that its consideration of the veteran's service-connected gastrointestinal disability under both the new and old criteria is not prejudicial to the veteran, as current medical evidence demonstrates only mild symptoms due to the service-connected gastrointestinal disability, and the current manifestations of this disability therefore do not warrant the current 60 percent rating under either the old or new criteria, let alone an increased rating. Hence there is no prejudice to the veteran in proceeding with this appeal. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993) (when the Board addresses a matter not addressed by the RO, the Board must provide an adequate statement of reasons and bases as to why there is no prejudice to the appellant). Under both the new and old rating criteria, disabilities of the digestive system are rated in accordance with 38 C.F.R. § 4.114, which provides that ratings under codes 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348 inclusive, will not be combined with each other. A single evaluation will be assigned under the diagnostic code which reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. 38 C.F.R. § 4.114 (2000); 38 C.F.R. § 4.114 (2001). Under the former rating criteria, infectious hepatitis with marked liver damage manifest by liver function test and marked gastrointestinal symptoms, or with episodes of several weeks duration aggregating three or more a year and accompanied by disabling symptoms requiring rest therapy shall be rated 100 percent. A 60 percent rating is provided with moderate liver damage and disabling recurrent episodes of gastrointestinal disturbance, fatigue, and mental depression. 38 C.F.R. § 4.114, Diagnostic Code 7345 (2000). Under the revised rating criteria, Diagnostic Code 7345 pertains to chronic liver disease without cirrhosis (including hepatitis B, chronic active hepatitis, autoimmune hepatitis, hemochromatosis, drug-induced hepatitis, etc., but excluding bile duct disorders and hepatitis C. A 100 percent rating is assigned for near-constant debilitating symptoms (such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain). A 60 percent rating is assigned for daily fatigue, malaise, and anorexia, with substantial weight loss (or other evidence of malnutrition), and hepatomegaly, or: incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain) having a total duration of at least six weeks during the past 12-month period, but not occurring constantly. 38 C.F.R. § 4.114, Diagnostic Code 7345 (2001). Under the revised criteria, hepatitis C is rated separately under Diagnostic Code 7354. A 100 percent rating is assigned for near constant debilitating symptoms (such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain). A 60 percent rating is assigned for daily fatigue, malaise, and anorexia, with substantial weight loss (or other evidence of malnutrition), and hepatomegaly, or: incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain) having a total duration of at least six weeks during the past 12-month period, but not occurring constantly. 38 C.F.R. § 4.114, Diagnostic Code 7354 (2001). Historical medical records indicate that the service- connected disability involves lengthy hospitalizations triggered by an initial case of varicella, now resolved. The veteran was then treated for varicella pneumonia, gastrointestinal bleeding, anemia, bacteremia, pancreatitis, hepatocellular disease, leukopenia secondary to Cleocin (clindamycin), and underwent laparotomies, a cholecystectomy, and an appendectomy. Post-service medical records show episodic treatment for abdominal pain of uncertain etiology in the first few years after service. More recent medical records, including treatment records and VA examinations, as well as the veteran's written statements and hearing testimony, indicate he has voiced a host of subjective complaints, primarily abdominal pain, which he attributes to his service-connected gastrointestinal disability. However, the veteran is a layman and thus has no competence to give a medical opinion on diagnosis or cause of symptoms. Espiritu, supra. The actual medical records from recent years indicate the service-connected gastrointestinal disability is not the source of the various problems of which the veteran complains. He has unrelated non-service- connected ailments (e.g., a narcotics addiction) which may be the source of his symptoms, and such non-service-connected conditions may not be considered in support of the claim for an increased rating for the service-connected condition. 38 C.F.R. § 4.14 (2001). The most recent medical evidence does not show any gastrointestinal symptoms due to the service-connected disability other than hepatitis C, which was described as mild, and not requiring treatment, in November 1998. In March 1999, Dr. Sonneland indicated that the veteran had no objective findings in recent years to substantiate a diagnosis of gastrointestinal disease. Hence, the Board finds that the veteran's gastrointestinal disability is most appropriately rated under the criteria pertaining to hepatitis. The medical evidence does not show that the veteran has liver function test and marked gastrointestinal symptoms, or with episodes of several weeks duration aggregating three or more a year and accompanied by disabling symptoms requiring rest therapy, and does not show that he has near constant debilitating symptoms (such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain). This supports no more than a 60 percent rating under Diagnostic Codes 7345 and 7354, under either the old or new rating criteria. Considering all the evidence, the Board finds that a rating in excess of 60 percent for the service-connected gastrointestinal disability is not warranted. As the preponderance of the evidence is against the claim for an increased rating, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b) (West Supp. 2001); Gilbert, supra. ORDER Service connection for an allergy disability is denied. Service connection for left arm neuropathy is denied. An increased rating in excess of 60 percent for a service- connected gastrointestinal disability is denied. RENÉE M. PELLETIER Member, Board of Veterans' Appeals IMPORTANT NOTICE: We have attached a VA Form 4597 that tells you what steps you can take if you disagree with our decision. We are in the process of updating the form to reflect changes in the law effective on December 27, 2001. See the Veterans Education and Benefits Expansion Act of 2001, Pub. L. No. 107-103, 115 Stat. 976 (2001). In the meanwhile, please note these important corrections to the advice in the form: ? These changes apply to the section entitled "Appeal to the United States Court of Appeals for Veterans Claims." (1) A "Notice of Disagreement filed on or after November 18, 1988" is no longer required to appeal to the Court. (2) You are no longer required to file a copy of your Notice of Appeal with VA's General Counsel. ? In the section entitled "Representation before VA," filing a "Notice of Disagreement with respect to the claim on or after November 18, 1988" is no longer a condition for an attorney-at-law or a VA accredited agent to charge you a fee for representing you.