Citation Nr: 1319059 Decision Date: 06/12/13 Archive Date: 06/21/13 DOCKET NO. 09-48 639 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Whether new and material evidence sufficient to reopen a claim of entitlement to service connection for right carpal tunnel syndrome has been submitted. 2. Entitlement to service connection for tinnitus. REPRESENTATION Appellant represented by: Missouri Veterans Commission WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD D. Rogers, Associate Counsel INTRODUCTION The Veteran served on active duty from July to November 1984 and from August 1985 to September 2005. These matters come before the Board of Veterans' Appeals (Board) on appeal from a March 2009 rating decision of the Department of Veterans Affairs (VA), Regional Office (RO), in St. Louis, Missouri, which declined to reopen the Veteran's claim for service connection for right carpal tunnel syndrome as it was found that new and material evidence had not been submitted, and denied service connection for tinnitus. In September 2012, the Veteran testified at hearing before a Decision Review Officer (DRO) the RO. A transcript of this proceeding is of record. The issues of entitlement to service connection for right carpal tunnel syndrome, on the merits, and tinnitus, are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. An unappealed May 2007 rating decision denied entitlement to service connection for right carpal tunnel syndrome, finding that the condition neither occurred in nor was caused by service. 2. Evidence received since the May 2007 rating decision raises a reasonable possibility of substantiating the Veteran's claim. CONCLUSIONS OF LAW 1. The May 2007 rating decision that denied the claim for entitlement to service connection for right carpal tunnel syndrome is final. 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. § 20.1103 (2012). 2. Evidence received since the May 2007 rating decision in relation to the Veteran's claim for entitlement to service connection for right carpal tunnel syndrome is new and material, thus, the claim may be reopened. 38 U.S.C.A. §§ 5108, 7104 (West 2002); 38 C.F.R. § 3.156 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all the evidence submitted by or on behalf of the Veteran. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). Veterans Claims Assistance Act of 2000 (VCAA) The VCAA describes VA's duties to notify and assist veterans in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). As discussed in more detail below, sufficient evidence is of record to grant the application to reopen the Veteran's claim for entitlement to service connection for right carpal tunnel syndrome. Thus, any errors in complying with the notice or assistance requirements with respect to that matter are moot. The claim on the merits requires additional development, which is addressed in the remand below. New and Material Evidence The Veteran claims that her right carpal tunnel syndrome was diagnosed during her active military service, however, because her left carpal tunnel syndrome was worse and because she was right hand dominant and did not want to be handicapped with surgical treatment of her right hand, her service treatment records do not mention her right carpal tunnel syndrome. During service, she worked as a personnel specialist and did a lot of typing on electric type writers. She experienced tingling and numbness in her right hands and fingers prior to her discharge from service, which she has indicated should be documented in her separation reports of medical history and examination. Rating actions are final and binding based on evidence on file at the time the Veteran is notified of the decision and may not be revised on the same factual basis except by a duly constituted appellate authority. 38 C.F.R. § 3.104(a) (2012). The Veteran has one year from notification of a RO decision to initiate an appeal by filing a notice of disagreement (NOD) with the decision, and the decision becomes final if an appeal is not perfected within the allowed time period. 38 U.S.C.A. § 7105(b) and (c) (West 2002); 38 C.F.R. §§ 3.160(d), 20.201, and 20.302(a) (2012). The Veteran originally filed a claim of entitlement to service connection for right carpal tunnel syndrome in August 2006. The claim was denied in a May 2007 rating decision. The Veteran did not appeal the denial by submitting a timely Notice of Disagreement or other indication of disagreement with the rating decision within one year. The denial of her claim consequently became final. See 38 C.F.R. §§ 20.302, 20.1103 (2012). As a result, a claim for entitlement to service connection for right carpal tunnel syndrome may now be considered on the merits only if new and material evidence has been received since the time of the last final adjudication. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156 (2012); Manio v. Derwinski, 1 Vet. App. 140, 145 (1991); Evans v. Brown, 9 Vet. App. 273 (1996). Under 38 C.F.R. § 3.156(a), evidence is considered "new" if it was not of record at the time of the last final disallowance of the claim. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. Finally, new and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. In determining whether evidence is new and material, the "credibility of the evidence is to be presumed." Justus v. Principi, 3 Vet. App. 510, 513 (1992). Additionally, when determining whether the Veteran has submitted new and material evidence to reopen a claim, consideration must be given to all the evidence since the last final denial of the claim. Evans v. Brown, 9 Vet. App. 273 (1996). Moreover, the Veteran need not present evidence as to each element that was a specified basis for the last disallowance, but merely new and material evidence as to at least one of the bases of the prior disallowance. See Shade v. Shinseki, 24 Vet. App. 110 (2010) (holding that it would be illogical to require that a claimant submit medical nexus evidence when he has provided new and material evidence as to another missing element). As already noted, a claim of entitlement to service connection for right carpal tunnel syndrome was denied in a May 2007 rating decision. The evidence of record at the time of the May 2007 rating decision consisted of the Veteran's service treatment records, an August 2005 report of VA general medical examination, September 2005 reports of VA mental disorders and eye examinations, and a February 2007 report of a VA joints examination. The Veteran's STRs showed that she received treatment for neck pain, stiffness, and spasm in October 1985, 1986, and 1990 with notation that she was involved in a 1982 motor vehicle accident. An October 1985 cervical spine x-ray revealed straightening of the cervical lordosis. In a January 1996 survey for the purpose of "identifying and monitoring employees exposed to repetitive trauma" the Veteran denied health complaints relating to her job, however, she recommended that phone and wrist rests be purchase. In January 1998, she received treatment for a 1 month history of pain numbness in her right shoulder, mostly on lateral raise-type motion, without history of trauma, diagnosed as right shoulder pain, possible impingement verses bursitis. X-ray of the right shoulder revealed hypertrophic arthritis changes of the right AC joint. Radicular pain was denied during subsequent physical therapy treatment and findings were consistent with right shoulder impingement. In August 2003 report of medical history, the Veteran endorsed a history of numbness and tingling in her fingers/hands(pleural) on walking or running for long periods and distances greater than 1.5 miles. An associated August 2003 report of medical examination shows that the Veteran's skin was evaluated as abnormal, in relevant part, due to a scar on her left wrist. Her upper extremities, spine and other musculoskeletal system, and neurologic system, however, were evaluated as normal. In December 2004, initial complaints of pain, tingling, muscle spasm, and numbness in the left arm and hand were noted in service clinical treatment notes. Pain started in the left upper shoulder and went slightly anterior then down her arm all the way into her hand and fingers with numbness and tingling in her fingers. Examination revealed some restricted neck motion, particularly at C3-5 on the left, and some mild muscle tension in the paravertebral muscles along with the left trapezius muscle which showed some tenderness and mild spasm. Grip strength full and symmetric bilaterally (5/5). Cervical spine series showed spondylosis of C5-6 and C6-7 disc spaces. Some nerve root impingement, possibly neural foraminal narrowing, was suspected. MRI of the cervical spine in December 2004 revealed a prominent C5 disc herniation with cord impression and moderate herniations at C5-6 and at C6-7. In February 2005, she experienced primarily pain and numbness in her left arm. Foraminal compression testing in February 2005 caused pain to radiate to the arm on the same side to which the head was rotated. Left sided transformational cervical epidural steroid injections were performed at the C5 and C6 levels due to displacement of cervical disc without myelopathy and cervical radiculopathy. She was placed on a temporary limited physical profile for "C spine disc bulge with radiation to the left upper extremity. There was an approximate 80 percent improvement of symptoms of neck pain with some residual left-sided neck pain and tingling into the left fingers. A cervical 7 epidural was recommended but the Veteran declined. EMG of the upper extremities (plural) was to be obtained to delineate why the Veteran might be having some finger numbness. In April 2005, examination of the neck was positive for pain elicited by right lateral flexion and a feeling of tightness. On this occasion, foraminal compression test did not cause pain to radiate to the arm on the same side to which the head was rotated. In April 2005, a nerve study of the left upper extremity was performed due to a 3 month history of intermittent left hand numbness and tingling, increased at night and after exercise. Complaints of neck and shoulder pain were no longer a complaint. Physical examination showed symmetrically depressed reflexes of the upper extremities (pleural). Nerve study and electromyogram of the left upper extremity revealed moderate left carpal tunnel syndrome. There was no electromyographic evidence of left ulnar neuropathy or active left cervical radiculopathy. In June 2005, the Veteran submitted claims for service connection for multiple conditions, to include "right shoulder arthritis joint pain" and "left carpal tunnel syndrome." There was no mention of right carpal tunnel syndrome. A June 2005 report of medical history for purpose of retirement showed that the Veteran endorsed history of a painful shoulder, elbow or writ (e.g., pain dislocation, etc).; arthritis or bursitis; numbness or tingling; impaired use of arms, legs, hands, or feet, and; bone, joint, or other deformity. Explanation provided by the Veteran qualified pain, tingling, and numbness in her neck, left shoulder, wrist and hand and she indicated that she had received physical therapy for left-sided pain in her neck, wrist, hand, and knee. A report of medical assessment dated the same day, the Veteran stated that compared to her most recent examination, her overall health had worsened due to pain in both hands with numbness and tingling feeling among other things. She indicated that she intended to seek VA disability compensation for "numbness in hands. . . and neck pain through [her] left shoulder, arm, and hand." The associated June 2005 report of medical examination is negative for any markings showing that clinical evaluation was performed. In August 2005, while still in active duty service, the Veteran underwent a VA general medical examination for retirement purposes and related to her claims for service connection. Regarding a bulging cervical disc, the examiner noted cervical spine MRI findings from December 2004. Complaints during examination included stiffness on waking up, increased with repetitive activity; tingling in her hands (plural), left greater than right, and; neck pain at night rated as 7 out of 10 with 10 at worst. There were no aggravating factors and relief was obtained with heat and massage. She also took Tylenol arthritis. She had been given quarters following pain clinic treatment for her neck. She avoided exercise due to pain and it was hard to reach overhead. Regarding her right shoulder, the Veteran reported dislocation of her right shoulder after she fell from a truck. Right shoulder complaints included pain once a month for several minutes. Repetitive activity would cause pain. There were no precipitating factors and relief was obtained with moving, stretching, heat as needed, and over-the-counter pain medication. The examiner erroneously stated that there had been no x-rays of the right shoulder (see 1998 service treatment records). Right shoulder pain made it difficult to reach overhead and use her arms when in pain. Regarding left carpal tunnel syndrome, it been demonstrated on a nerve conduction study. Complaints included left wrist pain rated as 7 out of 10 with 10 at worst and numbness and tingling of her fingers that awoke her at night, worse with repetitive activity. Relief was obtained with medication (name unknown), movement, and use of a left wrist brace at night. Left carpal tunnel syndrome made it difficult to type, mow the grass, and manage pots and pans while cooking. Physical examination in August 2005 revealed full (5/5) and equal muscle strength of the biceps, triceps, and hand grip. Bilateral shoulder range of motion showed limited forward flexion (0 to 150/180 degrees), limited abduction (0 to 50/180 degrees), and full internal and external rotation (0 to 90 degrees) without arm drop, pain, discomfort, or fatigability on active, passive and repetitive motion. Range of motion of the bilateral wrists was normal without pain, discomfort, or fatigability on active, passive and repetitive motion. Diagnostic impressions were cervical disc disease, right shoulder pain with insufficient evidence to make a diagnosis of acute or chronic disorder or residual thereof with prior right shoulder dislocation, and left carpal tunnel syndrome. There was no mention of right carpal tunnel syndrome. In a December 2005 rating decision, the RO granted service connection for degenerative disc disease of the cervical spine and left carpal tunnel syndrome, among other things. In her initial August 2006 claim for service connection for right carpal tunnel syndrome, the Veteran stated that this condition was not rated with her left wrist. She simultaneously submitted a claim for increase for service-connected carpal tunnel syndrome of her left wrist. In February 2007, the Veteran was afforded a VA joints examination to determine the current severity of her left carpal tunnel syndrome and to determine if she had right carpal tunnel syndrome related to service. The claims file and medical records were reviewed in conjunction with the examination. Historically, left carpal tunnel release surgery was performed in 2006. Joint symptoms during the February 2007 examination included pain, stiffness, and weakness of the bilateral hands that affected the motion of 1 or more joints. The Veteran also had right carpal tunnel syndrome for which he planned to undergo surgical treatments for at least 6 months after surgical treatment of her left wrist in 2006. On physical examination, there was some limitation of motion on palmar flexion of the right wrist and dorsiflexion of the bilateral wrists. The examiner diagnosed bilateral carpal tunnel syndrome status post left carpal tunnel release in 2006. Although requested, an etiological opinion as to the Veteran's diagnosed right carpal tunnel syndrome was not provided. The Veteran submitted an application to reopen her claim of service connection for right carpal tunnel syndrome in January 2009. Evidence received since the May 2007 rating decision consists of post-service private, civilian military, and VA treatment records dating since 2005; January 2009 reports of VA QTC spine and peripheral nerve examinations; a February 2009 report of a VA QTC cognitive disorders examination; a November 2012 report of a VA headaches examination, and; statements and testimony of the Veteran concerning her in-service symptoms of right carpal tunnel syndrome. Again, the Veteran claims that her current right carpal tunnel syndrome had its onset during service, however, she declined to have it surgically treated during service because she was right hand dominant, her left carpal tunnel syndrome was worse, and she did not want both hands to be disabled due to surgery and recovery simultaneously. For evidence to be new and material in this matter, it must show that right carpal tunnel syndrome occurred during service or is otherwise caused or aggravated by event, injury, or disease during active service. The Board finds the evidence received since the May 2007 rating decision does. In this regard, during the January 2009 VA QTC spine and peripheral nerve examination, the Veteran indicated that during service in 1998 following a slip and fall accident off of a truck she developed pain in her neck with moderate shooting pain and stiffness down her arms (plural) and spine and mild weakness in her neck. She also reported that she had bilateral carpal tunnel syndrome. Additional symptoms related to her neck condition included numbness, among other things. Symptoms pertaining to bilateral carpal tunnel syndrome included tingling of her skin and numbness and tingling in her bilateral hands and fingers. Physical examination revealed limited range of motion of the cervical spine, especially on left lateral flexion, with complaints of neck pain. There were signs of intervertebral disc syndrome with evidence of motor impairment of the bilateral upper extremities. Bilateral upper extremity function was abnormal with most likely involvement of the median nerve affecting flexion of wrist and fingers, most likely due to carpal tunnel syndrome. The examiner was unable to determine if a spinal cord lesion was present, however, because there were no studies to indicate that the Veteran has a spinal cord lesion. The VA established diagnosis of degenerative disc disease of the cervical spine remained the same with notation of abnormal motor function related to the bilateral medial peripheral nerves affecting function of flexion of the wrists and fingers. The VA established diagnosis of left carpal tunnel syndrome also remained unchanged and the most likely etiology was from repetitive use. The examiner's additional comments indicated that bilateral grip strength was +3 - 4. As to the Veteran's reported history of right carpal tunnel syndrome with corrective surgery, the examiner noted that Tinel's sign was positive bilaterally and that the condition is moderate. In her notice of disagreement received in May 2009, the Veteran indicated that her military occupation was a human resources specialist, which involved frequent repetitive movement with typing. She reported that she had constant problems with both wrists during service, however, she elected to have surgery on her left wrist first as it was the worse wrist and because she is right hand dominant. Also in May 2009, the Veteran submitted new evidence that was not previously of record, to include a report of a May 2006 cervical spine MRI, a September 2006 private operative report of section of the left transverse carpal ligament due to left-sided carpal tunnel syndrome, an April 2007 post-service military treatment note, an April 2007 report of EMG/NCS testing of the right upper extremity, and a November 2008 private operative report of section of the right transverse carpal ligament due to right-sided carpal tunnel syndrome. The May 2006 MRI report showed that it was performed due to symptoms of bilateral hand numbness with known bulging cervical discs. MRI revealed chronic but worsening degenerative disc disease, especially at the C4-5 level. The September 2006 private operative report from Dr. JFF, MD, indicated that the Veteran presented with a history of progressive neck pain with bilateral hand numbness with evidence of cervical spine spondylosis at multiple levels and NCV studies which confirmed the presence of bilateral carpal tunnel syndrome. The April 2007 post-service military treatment note shows that the Veteran reported a history of intermittent tingling and numbness since 2 to 3 years prior, and that she had been diagnosed with bilateral carpal tunnel syndrome, left greater than right, per medical records. The April 2007 report of EMG/NCS testing of her right upper extremity indicated that there is electrophysiological evidence of a right moderate grade III median nerve lesion at or about the right wrist. Significantly, findings suggested that the lesion was more chronic in nature due to electrophysiological findings suggestive of prior mild axonal degeneration of the motor fibers with subsequent motor unit remodeling and muscle fiber reinnervation. There was no electrophysiological evidence suggestive of ongoing axonal degeneration of the motor fibers. The November 2008 private operative report from Dr. JFF, MD, the same physician who provided surgical treatment for left carpal tunnel syndrome, pertaining to section of the right transverse carpal ligament noted persistent and progressively severe right hand numbness, motor weakness. In her December 2009 substantive appeal, the Veteran reiterated that she was treated for bilateral carpal tunnel syndrome during service, however, because she is right hand dominant and worked as a personnel specialist which involved repetitive typing during service, surgery was performed on the left wrist first. She was not going to have surgery on both wrists at the same time due to her continuous mission as a personnel specialist. In June 2012, the Veteran submitted all post-service civilian military and private medical records dating since 2005. An October 2005 treatment note, dated only days following her discharge from active service, showed complaint of numbness and tingling in her hands (plural). A June 2006 private treatment note from Dr. JFF, MD, indicates that the Veteran had a history of intermittent neck pain since 2004 with associated numbness in her bilateral hands, left greater than right and some weakness in her bilateral hands. Diagnostic impression at that time was bilateral carpal tunnel syndrome and NCV testing of the bilateral medial nerve was ordered with instruction to follow-up as soon as possible. On follow-up with Dr. JFF in July 2006, still less than 1 year after the Veteran's discharge from service, it was noted that EMG/NCV testing of the upper extremities showed bilateral carpal tunnel syndrome, left greater than right. During the September 2012 DRO hearing, the Veteran testified that she experienced symptoms of right carpal tunnel syndrome during service of tingling and loss of feeling in her right hand, which she associated with repetitive movement of typing on an electronic typewriter. She stated that she was diagnosed with bilateral carpal tunnel syndrome during service, however, her treatment records are essentially silent as to symptoms in her right hand because it was not as bad as her left hand, and because she was right hand dominant and did not desire simultaneous surgical treatments of both hands or of her right hand for occupational and functional reasons. She stated that she reported symptoms of her right carpal tunnel syndrome during separation examination. Her representative also requested secondary service connection be considered for right carpal tunnel syndrome secondary to cervical degenerative disc disease. He further requested that the Veteran's testimony be considered new and material evidence with which to reopen the claim. Thus, there is now new lay and medical evidence of record linking the Veteran's right carpal tunnel syndrome to her military service and complaints of numbness and tingling in her hands (plural) during service. Pursuant to the Court's recent holding in Shade and presuming the credibility of the evidence for the sole purpose of determining whether the claim should be reopened, the Board concludes that the above lay and medical evidence, all of which was received for review subsequent to the May 2007 rating decision, date the onset of the Veteran's right carpal tunnel syndrome to military service and/or link it to an event, injury, or disease during service, and at the very least, raises a reasonable possibility of substantiating the claim and constitutes new and material evidence sufficient to reopen the Veteran's claim. However, as will be discussed more fully below, the Board finds that additional development is necessary prior to adjudication of the claim of entitlement to service connection for right carpal tunnel syndrome, on the merits. ORDER New and material evidence having been received, the claim for entitlement to service connection for right carpal tunnel syndrome is reopened; the appeal is granted to this extent only. REMAND A review of the claims file reveals that a remand is necessary before a decision can be reached on the merits for the issues of entitlement to service connection for right carpal tunnel syndrome and tinnitus. The duty to assist required under the VCAA includes providing a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on the claim. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). In McLendon v. Nicholson, the Court held that the Secretary must provide a VA medical examination when there is: (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service, or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service or with another service-connected disability, but (4) there is insufficient competent medical evidence on file for the Secretary to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006). As to the Veteran's right carpal tunnel syndrome, the evidence outlined above shows that she did in fact report symptoms of numbness and tingling in her hands on running and walking for long distances as early as August 2003. In December 2004, MRI of the cervical spine was ordered because it was suspected that complaints of pain, numbness, and tingling in the hand were related to possible cervical nerve root impingement or foraminal narrowing. In February 2005, it was noted that foraminal compression testing caused pain to radiate to the arm on the same side to which the head was rotated. While the Veteran's report of medical history on retirement examination in June 2005 qualifies such symptoms to her left hand, a contemporaneous report of medical assessment explicitly states that she had "pain in both hands - numbness and tingling feeling." Dr. JFF, M.D., provided an initial formal diagnosis of bilateral carpal tunnel syndrome in June 2006, which was subsequently confirmed on neurological testing as noted in a July 2006 treatment note, approximately 10 months following the Veteran's discharge from service. Although the Veteran was afforded a VA QTC examination in January 2009 where the RO requested that the examiner provide an etiological opinion as to any finding of right carpal tunnel syndrome found on examination, as noted above, the examiner failed to provide the opinion as requested. Under these circumstances, a new medical opinion must be obtained to determine whether the Veteran's right carpal tunnel syndrome was incurred in or aggravated by service or service connected disability. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Veteran also asserts that she has bilateral tinnitus which reportedly had onset during or is related to noise exposure and acoustic trauma from performing routine maintenance on military vehicles in motor stables, tanks, explosions, and artillery during boot camp and mandatory field trainings and drills for two weeks at a time without use of hearing protection. During the September 2012 hearing, she testified that although her military occupations as a personnel and a human resources specialist were administrative in nature, she nevertheless was required to perform field trainings and drills with her unit of assignment, which was an infantry unit. She further testified that she was a qualified with an M-16 rifle which required that she undergoing refresher trainings and/or re-qualify every six months which entailed shooting approximately 40 hours of ammunition on each occasions. She stated that she was not provided with any form of hearing protection during boot camp. Later in service she was given sponge-like ear plugs for hearing protection and closer to the time of her discharge in 2005, she was provided with custom fitted hearing protection devices and use was required and considered part of her daily uniform. She stated that she gradually developed a low to high pitched buzzing noise in her ears, which she thought was normal, however, it gradually became louder and interfered with her sleep. She did not know that what she had was tinnitus or that it was a disability for which she may be compensated, thus, she could not pinpoint a date of onset, however, it was sometime during active service and prior to her reported diagnosis with hearing loss in 2006 or 2007. Following service she worked as a cab driver for short while prior to obtaining employment as a contract security guard at Fort Leonard Wood during which she experiences noise exposure to weapons during qualification and to traffic driving under the canopy where she works. While a review of the Veteran's service treatment records is negative for any complaint, finding, or diagnosis of tinnitus, service hearing conservation data and audiological testing reports show that Veteran was documented to be routinely exposed to hazardous noise exposure in October 1988. A December 1995 occupational health note states that the Veteran had occasional exposures to noise hazards. In July 2000, the Veteran was noted to have routine noise exposure and her hearing profile was H-1. In June 2002, the Veteran continued to experience routine noise exposure and audiometric testing showed a significant threshold shifts ranging from 15 to 30 decibels in the right ear and from 0 to 5 decibels in the left ear. On recheck two days later, there was no significant threshold shift. Post-service private treatment records from Dr. JFF, M.D., show that tinnitus was either denied or review of symptoms was negative for tinnitus in June 2006 and September 2008. During a March 2009 ENT evaluation, the Veteran reported experiencing tinnitus for "a couple of years," which reportedly had become louder and more annoying in the last 6 months. January 2011 pre-employment audiological testing for a position as a security guard showed that any ear problems were denied, however, puretone screening diagnosed high frequency hearing loss in the right ear. To date, the Veteran has not been afforded a VA audiological examination to determine if her currently diagnosed bilateral tinnitus disability may be related service and military noise exposure documented therein. Of note, the Veteran reported tinnitus with an onset during service and since separation. The Veteran is competent to report such ongoing symptoms. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). Given the foregoing, the Board finds that a VA examination for the Veteran's claimed ear, nose, and throat disabilities is warranted. Furthermore, the RO/AMC should take the opportunity to obtain and associate with the claims file VA treatment records from March 2012 to the present. Accordingly, the case is REMANDED for the following action: 1. Obtain all medical records for the Veteran's right carpal tunnel syndrome and tinnitus disabilities from all applicable facilities, to include any ongoing treatment records from the Columbia VAMC dating since March 2012. Any negative responses should be documented in the file and the Veteran must be provided with an opportunity to provide such medical records. 2. After completion of the above development to the extent possible, schedule the Veteran for an examination with an appropriate examiner to determine the nature, severity, and etiology of the Veteran's claimed tinnitus disability. The examiner is requested to review the entire claims file in conjunction with the examination. The examiner should elicit a complete history from the Veteran as to her claimed tinnitus disability and assume, and specifically state as such, that the Veteran did sustain acoustic trauma from military vehicles, tanks, and artillery noise during service. Based on a review of the claims file, to include any electronic VA treatment records in Virtual VA, the examiner is requested to offer an opinion as to whether it is at least as likely as not the Veteran's tinnitus was caused by in-service acoustic trauma. A complete rationale should be given for all opinions and conclusions. Such rationale must include a discussion of all relevant evidence in the claims file (to include notation of what appeared to be a temporary shift in hearing during audiological evaluation in 2002; audiometric testing performed during the Veteran's active duty service; complaints and diagnoses reflected in the post-service treatment records; and the Veteran's lay statements concerning the onset, duration, and severity of her reported tinnitus disability), relevant findings on examination and from the Veteran's stated history, and applicable medical principles. All findings, conclusions, and supporting rationale should be expressed in a typewritten report. 3. After completion of the above development to the extent possible, obtain a medical opinion as to the nature and etiology of the Veteran's right carpal tunnel syndrome disability. The examiner is requested to review the entire claims file in conjunction with the examination. Based on a review of the claims file, to include any electronic VA treatment records in Virtual VA, the examiner is requested to offer an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran's right carpal tunnel syndrome disability occurred during or was caused by or is otherwise related to any event, injury, or disease during service. If not, the examiner is requested to offer an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran's right carpal tunnel syndrome is caused or aggravated by (increased in severity beyond its natural progression) her service-connected degenerative disc disease of the cervical spine. In the case of aggravation, to the extent practicable, the examiner should indicate a baseline of symptomatology for the Veteran's carpal tunnel syndrome, and the aggravation of such symptomatology by her service-connected degenerative disc disease of the cervical spine. A complete rationale should be given for all opinions and conclusions. Such rationale must include a discussion of all relevant evidence in the claims file (to include notation of complaints of pain, tingling, and numbness in her hands during service examinations dated in 2003 and on retirement examination in 2005; MRI and x-ray evaluations of her cervical spine with notation of clinical history of symptoms in her hands; complaints and diagnoses reflected in the post-service treatment records, to include formal diagnosis of bilateral carpal tunnel syndrome in June 2006 with confirmation on neurological testing by July 2006, approximately 9 or 10 months after separation from military service; and the Veteran's lay statements concerning the onset, duration, and severity of her right carpal tunnel syndrome disability), relevant findings on post-service examinations and from the Veteran documented history, and applicable medical principles. All findings, conclusions, and supporting rationale should be expressed in a typewritten report. 4. The Veteran is to be notified that it is her responsibility to report for the examination and to cooperate in the development of the claims. The consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2012). 5. After the development requested has been completed, the RO/AMC should review the examination report(s) to ensure that they are in complete compliance with the directives of this REMAND. If the report is deficient in any manner, the RO/AMC must implement corrective procedures at once. 6. After the completion of any action deemed appropriate in addition to that requested above, the RO/AMC must readjudicate the claims. If any benefit sought remains denied, the appellant and her representative should be provided a supplemental statement of the case and given the opportunity to respond before the case is returned to the Board. 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). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals 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 (West Supp. 2012). ______________________________________________ MICHAEL LANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs