Citation Nr: 1315074	
Decision Date: 05/07/13    Archive Date: 05/15/13

DOCKET NO.  99-08 489	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Medical and Regional Office Center in Wichita, Kansas


THE ISSUES

1.  Entitlement to service connection for bilateral carpal bony cysts claimed as numbness of the hands and arms.  

2.  Entitlement to service connection for upper and lower gastrointestinal disorders, including as due to an undiagnosed illness. 

3.  Entitlement to service connection for unexplained chronic multi-system illness, to include chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome, including as due to an undiagnosed illness.


REPRESENTATION

Appellant represented by:	Disabled American Veterans



ATTORNEY FOR THE BOARD

D. Havelka, Counsel


INTRODUCTION

The Veteran served on active duty from June 1978 to May 1992, and from February 2003 to February 2004. 

This matter comes before the Board of Veterans' Appeals (Board) on appeal of an August 1997 rating decision by the Department of Veterans Affairs (VA) Medical and Regional Office Center (RO) located in Wichita, Kansas. 

The Board has recharacterized the issue involving service connection for numbness of the hands and arms to reflect the present diagnosis of the disability of record.  

This appeal contains a hybrid record; part is in a physical claims folder and in part is in the Virtual VA paperless claims processing system.  Any future consideration of this appellant's case should take into consideration the existence of this electronic record.

This case has been remanded four times, most recently in November 2012, so that additional development, to include affording the Veteran appropriate VA examinations, could be conducted.  Unfortunately additional development is required.  

The issues of entitlement to service connection for upper and lower gastrointestinal disorders, and unexplained chronic multi-system illness are remanded to the RO via the Appeals Management Center.




FINDINGS OF FACT

1.  The Veteran served on active duty in the Army from June 1978 to May 1992; his military specialty during this time was as a vehicle mechanic. 

2.  The Veteran has a current diagnosis of bilateral carpal bony cysts.  

3.  The medical evidence of record links the Veteran's current bilateral carpal bony cysts to service and his duties as a vehicle mechanic during service.  


CONCLUSION OF LAW

Bilateral carpal bony cysts, claimed as numbness of the hands and arms, were incurred in active military service.  38 U.S.C.A. §§ 1110, 1131, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.303 (2012).


REASONS AND BASES FOR FINDINGS AND CONCLUSION

VA is required to meet the notice and duty to assist provisions of 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 and 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326.  Given the favorable outcome below, no conceivable prejudice to the Veteran could result from the grant of service connection for the Veteran's claimed disability of the hands and arms.  See Bernard v. Brown, 4 Vet. App. 384   (1993). 

Service connection may be granted for disability due to a disease or injury that was incurred in or aggravated by active service.  38 U.S.C.A. § 1110; 38 C.F.R. § 3.303.  In addition, service connection may be granted for any disease diagnosed after separation, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service.  38 C.F.R. § 3.303(d).  

Historically, the Veteran served on active duty in the Army from June 1978 to May 1992, and from February 2003 to February 2004.  He served in the Southwest Asia Theater of operations from December 1990 to May 1991. 

The Veteran is seeking service connection for a disability which he has claimed as numbness of the hands and arms.  The Veteran attributes this condition to his service in the Southwest Asia Theater of operations from December 1990 to May 1991.  The Veteran has specifically set forth that the claimed disorder came into existence only after his service in the Southwest Asia Theater of operations during the Persian Gulf War.  Service connection may also be warranted for a Persian Gulf Veteran who exhibits objective indications of a qualifying chronic disability that became manifest during active military, naval or air service in Southwest Asia Theater of operations during the Persian Gulf War or to a degree of 10 percent or more not later than December 31, 2011.  38 U.S.C.A. § 1117; 38 C.F.R. § 3.317.   However, based upon the rationale for the grant of service connection below, further consideration for the criteria under 38 C.F.R. § 3.317 is not warranted.  

The record reveals that the Veteran served on active duty in the Army from June 1978 to May 1992.  His military specialty during this period of time was as a vehicle mechanic.  The Veteran's service treatment records do not reveal any complaints of hand of arm numbness during this period of service.  

A private medical record dated September 1992, only 4 months after he separated from service, reveals that he sought treatment for complaints of numbness and tingling of the thumb, index finger, and middle finger of his right hand.  At the time the diagnosis was nerve entrapment of the right hand secondary to shoulder strain.

After the Veteran separated from active duty in May 1992, he served in the National Guard.  On a May 1998 National Guard medical examination medical history he reported that had symptoms of intermittent pain and swelling of both hands dating back at least four years.  

In June 1997 a VA Compensation and Pension examination of the Veteran was conducted.  He reported having numbness in both hands and fingers.  He reported being a mechanic during active service and that he was still employed as a mechanic.  He reported a prior diagnosis of carpal tunnel syndrome.  Physical examination of the hands revealed no swelling or deformity and good sensation of the hands and fingers.  

In October 2009 another VA Compensation and Pension examination of the Veteran was conducted.  He again reported symptoms of tingling and numbness of the right hand and fingers.  The diagnosis was mild paresthesias of the distal tips of the right index and third digit, more likely caused by early right carpal tunnel syndrome.  

In February 2011, another Compensation and Pension examination of the Veteran was conducted, but it did not focus on the reported symptoms of numbness of the hands and arms.  

In December 2012, the most recent VA examination of the Veteran was conducted.  X-ray examination of both wrists revealed the presence of bilateral carpal bony cysts.  The Veteran reported symptoms of tingling and numbness of the hands with overhead work as a mechanic.  He also reported difficulty gripping tools.  Neurologic examination revealed symptoms of paresthesias, dysesthesias, and numbness of both upper extremities which was moderate on the right and severe on the left.  The diagnosis was bilateral carpal bony cysts and the examiner's medical opinion was that the condition was at least as likely as not incurred in service.  The examiner specifically indicated that the Veteran's symptoms were associated with his work as a mechanic.  

The Veteran served in the Army as a mechanic from 1978 to 1992.  He was treated for symptoms of hand numbness in 1992 shortly after he separated from service.  He has reported continued symptoms of hand and forearm tingling and numbness, especially with working with his arms above his head as a mechanic.  The current diagnosis, verified by x-ray examination, is bilateral carpal bony cysts; essentially carpal tunnel syndrome.  While the Veteran continued to work as a mechanic subsequent to service, he did work as a mechanic for 14 years during his active duty service.  The 2012 medical opinion links the Veteran's current disability to service and specifically indicates that his symptoms are the result of his work as a mechanic.  In light of the symptoms of hand numbness being documented shortly after service, and the medical opinion linking the Veteran's current disability to service and his duties as a mechanic, the preponderance of the evidence is not against the claim.  Accordingly, service connection for bilateral carpal bony cysts, claimed as numbness of the hands and arms is granted.  

ORDER

Service connection for bilateral carpal bony cysts, claimed as numbness of the hands and arms, is granted.


REMAND

The Veteran claims entitlement to service connection for upper and lower gastrointestinal disorders, including as due to an undiagnosed illness.  He also clams service connection for an unexplained chronic multi-system illness, to include chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome, including as due to an undiagnosed illness.  These claims are made pursuant to 38 C.F.R. § 3.317.  

The Veteran reports that he has symptoms of diarrhea, which manifested during service in South West Asia and have continued ever since.  The record indicates some diagnosis of irritable bowel syndrome (IBS).  

In December 2012, the most recent VA Compensation and Pension examination of the Veteran was conducted.  The examiner acknowledged that the Veteran reported having diarrhea of "watery liquid stools 1-2 times daily."  The examiner indicated that the Veteran did not have treatment, or a colonoscopy, to warrant a diagnosis of IBS and that the claimed condition was less likely than not related to service.  The examiner specifically indicated that the Veteran did not meet the criteria for IBS, but then indicated the criteria for IBS as found on the Mayo clinic's web site.  Review of the criteria indicates that symptoms of diarrhea alone can meet the criteria for a diagnosis of IBS.  Moreover, the examiner also indicated that "there are many causes of diarrhea which include viruses, bacteria and parasites, medication, lactose intolerance, fructose, and artificial sweeteners."  The examiner did not appear to consider the chronic long-term reported symptoms of diarrhea being present from service in South West Asia until the present.  The examiner did not consider, nor offer an opinion related to, the criteria for undiagnosed illness for Persian Gulf veterans which is key criteria applicable to the present claim.  Accordingly, clarification of the medical opinion is necessary.  

When the medical evidence is inadequate, VA must supplement the record by seeking an advisory opinion or ordering another medical examination.  Colvin v. Derwinski, 1 Vet. App. 171 (1991); Hatlestad v. Derwinski, 3 Vet. App. 213 (1992).

Accordingly, the case is REMANDED for the following action:

1.  Return the claims file to the examiner who conducted the December 2012 Compensation and Pension examination.  If this examiner is not available, the claims file should be forwarded to a physician of the appropriate medical specialty for gastrointestinal disabilities.  The examiner should review the December 2012 Compensation and Pension examination report, the claims file and all records on Virtual VA must be made available to the examiner, and the examiner must specify in the examination report that the claims file and Virtual VA records have been reviewed.  The examiner must specify the dates encompassed by the Virtual VA records that were reviewed.  After review the examiner should answer the following:

* Why is a diagnosis of IBS warranted, or not, in light of the fact that the Mayo clinic criteria referenced in the 2012 examination report indicates that diarrhea alone can warrant such a diagnosis and the Veteran has reports symptoms of chronic diarrhea dating from service in South West Asia in 1992 to the present?

* If a diagnosis of IBS is not warranted, are the Veteran's symptoms of chronic diarrhea dating from service in South West Asia in 1992 to the present gastrointestinal signs or symptoms which may be manifestations of undiagnosed illness or medically unexplained chronic multisymptom illness?

A complete rationale for all opinions must be provided.  If the examiner cannot provide a requested opinion without resorting to speculation, it must be so stated, and the examiner must provide the reasons why an opinion would require speculation.  The examiner must indicate whether there was any further need for information or testing necessary to make a determination.  If additional examination is necessary to render the requested medical opinions, then the appropriate examination(s) should be ordered.  Additionally, the examiner must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner.  The report prepared must be typed.

2.  The medical report must be reviewed to ensure that it is in complete compliance with the directives of this remand.  If a report is deficient in any manner, corrective procedures must be implemented.  

3.  After completing the above actions, and any other development as may be indicated by any response received as a consequence of the actions taken above, the claims on appeal must be readjudicated.  If any benefit on appeal remains denied, a supplemental statement of the case must be provided to the Veteran and his representative.  After the Veteran and his attorney have had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review.  

No action is required by the Veteran until he receives further notice; however, he may present additional evidence or argument while the case is in remand status at the RO.  Kutscherousky v. West, 12 Vet. App. 369 (1999). 



______________________________________________
JOY A. MCDONALD 
Veterans Law Judge, Board of Veterans' Appeals



Department of Veterans Affairs