Citation Nr: 1308486 Decision Date: 03/13/13 Archive Date: 03/20/13 DOCKET NO. 10-40 476A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to service connection for left hand radial arterial insufficiency. 2. Entitlement to service connection for a cervical spine disorder. 3. Entitlement to service connection for skin disorder, to include chloracne. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD S. M. Kreitlow INTRODUCTION The Veteran had active military service from November 1968 to July 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. The Veteran appeared and testified at a Board hearing held at the RO before the undersigned Veterans Law Judge in May 2012. A copy of the transcript of this hearing has been associated with the claims file. A review of the transcript demonstrates that the Veterans Law Judge complied with the requirements set forth in Bryant v. Shinseki, 23 Vet. App. 488, 491-93 (2010). The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if further action is required. REMAND The Board notes that, at his hearing in May 2012, the Veteran provided more detailed information regarding his claimed conditions and treatment he has received for them. Based upon his testimony, the Board finds that remand is warranted for the following additional development. Initially, the Board notes that the Veteran testified that he was initially seen by private medical care providers for his claimed conditions but that he had switched his care over to the VA Medical Center in Fayetteville, North Carolina. The Board notes that VA treatment records are only of record from November 2007 through June 2008. Although the November 2007 Internal Medical note indicates he was a new patient, it was also noted that he was followed for colon cancer in gastroenterology and had just had a colonoscopy in July 2007 suggesting that there might be treatment records prior to November 2007. In addition, at the hearing, the Veteran stated he had been treated for his skin disorder at Fayetteville until a few months before when its Dermatology Clinic was closed. Thus, there are likely treatment records relating to his claim for a skin disorder. Consequently, the Board finds that there are likely outstanding VA treatment records from the Fayetteville VA Medical Center that have not been associated with the Veteran's claims file. A remand to obtain such records is required. With regard to the Veteran's claim for service connection for left hand radial arterial insufficiency, the Veteran related this condition to an injury he received in Vietnam to his left wrist. He testified that he injured his left wrist during a fire fight with the enemy when he was going to the tank to retrieve some ammunition. He stated that there was an explosion that knocked him from the tank and he fell on his wrist and injured it. He testified that the next day he was medevaced (air-vac'd) out to a hospital where they casted his left hand and then sent him back out to the field. The Board notes that the service treatment records are silent as to treatment for this injury. The only record of this injury is on the Veteran's DA20 which lists under "Wounds" that he had a "possible broken wrist" in August 1969. Given the Veteran's testimony of having been medevaced out and having a cast placed on his left hand and the notation on the DA20, the Board finds there possibly are clinical hospital records available to show treatment for this injury. In order to obtain them, however, more information is needed from the Veteran as to where he was medevaced and, preferably, the name of the hospital he was treated at. If the Veteran is not able to provide such detailed information, then efforts should be undertaken to obtain unit records that may show where the Veteran was sent for treatment. The Veteran further testified at the hearing that this was when he initially started having problems with his left hand. He stated that he currently experiences numbness and tingling in the left hand and fingers. He also stated that his hand is very sensitive to cold and, when he was a paramedic, exposure to cold caused his fingers to turn black and blue. He testified he was initially treated for his left hand condition at Highsmith-Rainey Medical Center, a private hospital. The Board notes that the Veteran has already submitted records from this hospital from March 1988. The records, however, only show that he underwent an arteriogram which diagnosed the radial arterial insufficiency. The Veteran, however, testified that he has undergone additional work up for this problem to include electrodiagnostic testing (i.e., electromyogram and nerve conduction velocity tests). He did not, however, specify whether such work up was by a private medical care provider or VA. Thus, on remand, he should be asked to identify when and where else he has received treatment, to include the electrodiagnostic work up, for his left hand radial arterial insufficiency and, if by a private medical care provider, to provide a release for VA to obtain those records. Finally, the Board finds that the evidence is sufficient to trigger VA's duty to assist the Veteran by obtaining a VA examination to determine whether the left hand radial arterial insufficiency first diagnosed post-service is related to the injury to the left wrist (noted to be a possible fracture) and/or treatment therefor. A medical examination or medical opinion is necessary if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim but (1) contains competent lay or medical evidence of a current diagnosed disability or persistent or recurrent symptoms of a disability; (2) establishes that the Veteran suffered an event, injury, or disease in service; and (3) indicates that the claimed disability or symptoms may be associated with the established event, injury, or disease in service. The third part could be satisfied by competent evidence showing post-service treatment for a condition or other possible association with military service. 38 C.F.R. § 3.159(c)(4). The threshold for establishing the third element is low for there need only be evidence that "indicates" that there "may" be a nexus between the current disability and military service. McLendon v. Nicholson, 20 Vet. App. 79 (2006). As for the Veteran's claim for a cervical spine disorder, the Board notes that private medical evidence from 2006 through 2008 (to include reports of X-rays and a magnetic resonance imaging (MRI) study of the cervical spine) demonstrate the Veteran has a current diagnosis of severe multilevel degenerative disc disease and degenerative joint disease of the cervical spine with multifactorial central and foraminal stenosis and a very mild grade I subluxation of the C4 over the C5. The Veteran has submitted statements and testimony that he relates the current condition of his cervical spine to being struck on the head several times with a tank lid hatch (both when he was in Vietnam and Germany). He admitted he did not seek treatment for any of these instances or for complaints of neck pain relating thereto while in service, saying that it was frowned upon to seek medical treatment for something that was not life threatening since it was war time. He testified that he has continuously sought treatment for his neck since service. The Board notes, however, that the earliest treatment record in the claims file showing complaints of neck pain is an October 2006 private treatment record and he was sent for X-rays and an MRI in December 2006, which showed the diagnoses noted above. The Board further notes that the report of a March 2007 neurosurgeon consultation shows the Veteran reported that he worked as a registered nurse for VA and had previously worked as a paramedic. He reported that he had done a fair amount of lifting in the past. Finally, the Board notes that these treatment records also demonstrate that the Veteran complained of low back pain as well and an MRI of the lumbar spine showed multilevel degenerative disc disease and degenerative joint disease. The Board notes that the Veteran's service records indicate his military occupational specialty was track vehicle mechanic, which the Board supposes would include the Veteran driving a vehicle like a tank for various purposes. Thus, his report of being hit on the head multiple times with a tank lid hatch is not inconsistent with the types, circumstances and places of his service. The Board notes that the Veteran has not been provided with a VA examination. After considering the evidence, the Board finds that there is sufficient evidence to raise VA's duty to assist the Veteran in providing him with a VA examination and to obtain a medical opinion as to whether there is a relationship between the Veteran's current cervical spine degenerative disc disease and degenerative joint disease and his complaints of injury to his neck in service. As for the Veteran's claim for service connection for a skin disorder, the Veteran testified that some of his medical evidence in the claims file does state he had chloracne. The Board is unable, however, to identify any medical evidence showing a diagnosis of chloracne. The Veteran's service treatment records show that he was noted at the time of his enlistment examination in October 1968 to have noncystic acne of mild to moderate severity (but does not list where said acne was). The first in-service treatment note regarding a skin disorder is from April 1970, while he was in Vietnam, when the Veteran was noted to have "boils" on his back, as well as something on his face although what is unclear from the note. He was given an antibiotic and told to bathe with surgical soap. A couple of weeks later, he was seen for follow up and noted to have acne vulgaris with multiple nodules and collections in the back area. He was prescribed Tetracycline and told to wash with Phisodex soap. Subsequent treatment notes indicate that the Tetracycline was improving his acne. He was next seen in September 1970 (after he left Vietnam) for pustulous and cystic acne on the back and face. He was referred to Dermatology for excision of some old cystic lesions on his back. Dermatology's impression was sebaceous cysts over back. It incised and drained the cysts and gave him Tetracycline to take for 10 days. The last treatment note relating to a skin disorder in service is from March 1971. It was again noted the Veteran had cysts on his back. A few days later he had a sebaceous cyst removed from the left shoulder. Despite this history, there was no skin abnormality noted on the Veteran's separation examination conducted in June 1971. Although the Veteran testified that he has sought treatment for his acne problems since service, the only evidence of post-service treatment is from October 2006 through May 2007. Private treatment records for that period demonstrate the Veteran had a sebaceous cyst on his back, which was eventually drained in May 2007. Thus, on remand, the Veteran should be asked to identify all other medical care provider, either VA or non-VA, that have treated him since service for his skin disorder and, for each non-VA providers, he should provide a release so that VA can obtain those records. Furthermore, given the Veteran's statements and testimony in addition to the service treatment records and post-service medical treatment records, the Board finds that the evidence is sufficient to raise VA's duty to assist in obtaining a VA examination to determine the current nature of the Veteran's skin disorder and medical opinions as to whether his acne noted on entry was aggravated during service or whether his in-service and subsequently treated skin disorder is consistent with chloracne and, therefore, the result of exposure to herbicides while serving in the Republic of Vietnam. Accordingly, the case is REMANDED for the following action: 1. Associate with the Veteran's claims file all of his treatment records from the VA Medical Center in Fayetteville, North Carolina. 2. Contact the Veteran and ask him to identify all private medical care providers who have treated him for his claimed conditions since his separation from service in July 1971, including for his left hand radial arterial insufficiency and work up therefore (except for Highsmith-Rainey Medical Center as those records from March 1988, which are already in the claims file). For all providers identified, the Veteran should be asked to provide VA with a release of records for it to obtain the identified treatment records. The Veteran should be advised that he can provide these treatment records in lieu of providing the release. If the Veteran provides completed release forms, contact the identified medical care providers to obtain all available treatment records. A negative reply should be requested if any records are not available. The Veteran and his representative should be advised if any records are not available and given an opportunity to provide these records. 3. Contact the Veteran and ask him to identify where he was treated for the "probable broken wrist" in August 1969 while in the Republic of Vietnam. In other words, he should provide the name of the hospital that he testified at the May 2012 he was medevaced to for treatment and where his left hand was casted. If he is unable to specifically identify the hospital, he should at least identify the base he was sent to for treatment. If the Veteran is not able to provide such information, then efforts should be undertaken to obtain unit records, such as morning reports, that may show where the Veteran was taken for treatment. To that end, the Board notes that the Veteran's DA20 demonstrates he was assigned to H Company, 2nd Squadron, 11th Armored Cavalry Regiment while serving in the Republic of Vietnam. 4. Once the above development is completed and all attainable evidence is associated with the claims file, schedule the Veteran for the following VA examinations. The claims file must be provided to each examiner for review in conjunction with the examination, and such review should be noted in the examination report. Spine Examination for Cervical Spine Disorder - After reviewing the file and conducting any necessary testing, the examiner should render an opinion as to whether it is at least as likely as not (i.e., at least a 50 percent probability) that each current disorder of the cervical spine (shown on December 2006 MRI study and X-rays to be multilevel degenerative disc disease and degenerative joint disease of the cervical spine with multifactorial central and foraminal stenosis and a very mild grade I subluxation of the C4 over the C5) is related to any disease or injury incurred during service, specifically whether it is related to the Veteran's reported injuries to the head and/or neck resulting from hitting his head on tank lids multiple times while in Vietnam and Germany. In rendering the opinion, the examiner should also consider the Veteran's report of continuous symptoms since service, his post-service occupational history (which was noted in the March 2007 neurosurgeon's consultation note that includes a history of significant lifting), and the significance (if any) that the Veteran also has degenerative disc disease/degenerative joint disease of the lumbar spine. Examination for Left Hand Radial Arterial Insufficiency - After reviewing the file and conducting any necessary testing, the examiner should render a diagnosis as to whether the Veteran has any artery/vein or nerve disorder involving the left hand. If any disorder is found, the examiner should than render an opinion as to whether it is at least as likely as not (i.e., at least a 50 percent probability) that each current disorder found on examination is related to any disease or injury incurred during service, specifically whether it is related to a possible wrist fracture that was incurred in August 1969 and/or treatment therefor (as noted in the service records). Skin Examination - After reviewing the file and conducting any necessary skin examination and testing, the examiner should answer the following questions: a) Does the Veteran have a current skin disorder of the face or back? If so, what is the diagnosis? b) Is any currently diagnosed skin disorder is related to skin problems noted in service? c) If so, please offer an opinion as to whether the acne the Veteran was treated for in service from April 1970 to March 1971 is related to the acne noted on his entrance examination in October 1968? d) If so, is it at least as likely as not (i.e., at least a 50 percent probability) that the acne noted on his entrance examination in October 1968 underwent an increase in disability (i.e., whether the treatment for acne seen in the service treatment records from April 1970 to March 1971 represents a permanent worsening in severity) during his active military service? If so, was the increase in disability during service due to the natural progression of the skin disorder? e) Alternatively, is it at least as likely as not (i.e., at least a 50 percent probability) that the Veteran's skin disorder seen in the service treatment records and the post-service treatment records is consistent with chloracne rather than acne vulgaris, cystic acne and/or sebaceous cysts as characterized in these medical records? Each examiner should give a detailed explanation for the reasons for the opinion(s) provided. The medical reasons for accepting or rejecting the Veteran's theories of entitlement should be set forth in detail. If an examiner determines that he/she cannot provide an opinion without resorting to speculation, the examiner should explain the inability to provide an opinion, identifying precisely what facts could not be determined. In particular, he/she should comment on whether an opinion could not be provided because the limits of medical knowledge have been exhausted or whether additional testing or information could be obtained that would lead to a conclusive opinion. Jones v. Shinseki, 23 Vet. App. 382, 389 (2010). (The agency of original jurisdiction should ensure that any additional evidentiary development suggested by the examiner be undertaken so that a definite opinion can be obtained.) 5. Thereafter, the Veteran's claims should be readjudicated. If such action does not resolve the claims, a Supplemental Statement of the Case should be issued to the Veteran and his representative. An appropriate period of time should be allowed for response. Thereafter, these claims should be returned to this Board for further appellate review, if in order. 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 for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112. _________________________________________________ MICHAEL MARTIN Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252, only a decision of the Board is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b).