Citation Nr: 1616282 Decision Date: 04/25/16 Archive Date: 05/04/16 DOCKET NO. 14-25 410 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New York, New York THE ISSUES 1. Entitlement to service connection for residuals of bilateral photo refractive keratectomy (PFK). 2. Entitlement to service connection for right wrist disability, to include as due to undiagnosed illness or other qualifying chronic disability, pursuant to 38 U.S.C.A. § 1117. 3. Entitlement to service connection for irritable bowel syndrome (IBS), claimed as loss of appetite, stomach cramps, diarrhea, indigestion, and cramps, to include as due to undiagnosed illness or other qualifying chronic disability, pursuant to 38 U.S.C.A. § 1117. 4. Entitlement to service connection for a disability manifested by incoordination, excessive sweating, feeling faint, feeling weak, joint pain, low energy, muscle pain, muscle weakness, claimed as residuals of Mefloquine or as due to undiagnosed illness or other qualifying chronic disability, pursuant to 38 U.S.C.A. § 1117. 5. Entitlement to an initial compensable rating for ilioinguinal nerve damage as a residual of left inguinal hemiorrhaphy. 6. Entitlement to a total rating for compensation purposes based on individual unemployability (TDIU) due to service-connected disabilities. REPRESENTATION Appellant represented by: New York State Division of Veterans' Affairs ATTORNEY FOR THE BOARD L. A. Rein, Counsel INTRODUCTION The Veteran had active service from December 1999 to March 2010. These matters come to the Board of Veterans' Appeals (Board) on appeal from September 2011, September 2013, and August 2015 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in New York, New York. In his July 2014 substantive appeal (via a VA Form 9), the Veteran requested a video conference hearing before the Board; however, in March 2016 written correspondence the Veteran requested "to have the Travel Board hearing removed." Thus, the Board finds that the Veteran's request for a hearing before the Board has been withdrawn and may proceed with adjudication of the matters on appeal. As a result of statements made by the Veteran during a December 2010 VA eye examination, the Board finds that a TDIU claim has been raised by the record. See Rice v. Shinseki, 22 Vet. App. 447 (2009). The Board has jurisdiction to consider entitlement to a TDIU in an appealed claim for an increased rating when the issue is raised by assertion or reasonably indicated by the evidence, regardless of whether the RO expressly addressed the issue. Therefore, this issue has been added for current appellate consideration. This appeal was processed using the Virtual VA and Veterans Benefits Management System (VBMS) paperless claims processing systems. The issues of entitlement to service connection for a right wrist disability and for entitlement to a TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The Veteran has developed halos as a residual of PRK surgery in service. 2. Symptoms of a stomach disorder began during the Veteran's service, was later diagnosed as IBS and was incurred in service or resulted from a medically unexplained chronic multi-symptom illness. 3. The Veteran has an undiagnosed illness characterized by incoordination, excessive sweating, feeling faint, feeling weak, joint pain, low energy, muscle pain, and muscle weakness not attributable to a known clinical diagnosis, which have been present for at least six months, with periods of improvement and/or worsening, and have become manifest to at least a degree of 10 percent prior to December 31, 2016. 4. The Veteran's ilioinguinal nerve damage as a residual of left inguinal hemiorrhaphy is manifested through recurrent pain which results in incomplete nerve paralysis that is mild. CONCLUSIONS OF LAW 1. The criteria for service connection for residuals of bilateral photo refractive keratectomy are met. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303 (2015). 2. The criteria for service connection for IBS, claimed as loss of appetite, stomach cramps, diarrhea, indigestion, and cramps are met. 38 U.S.C.A. §§ 1110, 1117, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.317 (2015). 3. The criteria for service connection for a disability manifested by incoordination, excessive sweating, feeling faint, feeling weak, joint pain, low energy, muscle pain, muscle weakness are met. 38 U.S.C.A. §§ 1110, 1117, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.317 (2015). 4. The criteria for a compensable rating for ilioinguinal nerve damage as a residual of left inguinal hemiorrhaphy are not met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.124, Diagnostic Code 8630 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist Upon receipt of a substantially complete application, VA must notify the claimant and any representative of any information, medical evidence, or lay evidence not previously provided to VA that is necessary to substantiate the claim. The notice must: (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. 38 U.S.C.A. §§ 5103, 5103A, 5107 (West 2014); 38 C.F.R. § 3.159 (2015); Pelegrini v. Principi, 18 Vet. App. 112 (2004). If VA does not provide adequate notice of any of element necessary to substantiate the claim, or there is any deficiency in the timing of the notice, the burden is on the claimant to show that prejudice resulted from a notice error, rather than on VA to rebut presumed prejudice. Shinseki v. Sanders, 129 S.Ct. 1696 (2009). Given the favorable disposition of the Veteran's claims for service connection for residuals of bilateral PFK, a right wrist disability, IBS, and for a disability manifested by incoordination, excessive sweating, feeling faint, feeling weak, joint pain, low energy, muscle pain, muscle weakness, the Board finds that all notification and development action needed to fairly adjudicate these claims has been accomplished. With regard to the claim for an initial compensable rating for ilioinguinal nerve damage as a residual of left inguinal hemiorrhaphy, where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service connection claim has been more than substantiated, it has been proven, thereby rendering 38 U.S.C.A. § 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Dingess v. Nicholson, 19 Vet. App. 473 (2006); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). In any event, the Veteran received notification prior to the initial AOJ decision through a notice letter in March 2010. The content of the notice letter fully complies with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) regarding VA's duty to notify. The Board also finds that the duty to assist requirements have been fulfilled. All relevant, identified, and available evidence has been obtained, and VA has notified the appellant of any evidence that could not be obtained. The appellant has not referred to any additional, unobtained, relevant, available evidence. VA has obtained examinations with respect to the claims on appeal. Thus, the Board finds that VA has satisfied the duty to assist provisions of law. No further notice or assistance to the Veteran is required to fulfill VA's duty to assist him in development. Smith v. Gober, 14 Vet. App. 227 (2000); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated during service. 38 U.S.C.A. § 1110 (West 2014); 38 C.F.R. § 3.303 (2015). That determination requires a finding of current disability that is related to an injury or disease in service. Watson v. Brown, 4 Vet. App. 309 (1993); Rabideau v. Derwinski, 2 Vet. App. 141 (1992). Service connection may be granted for a disability diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability is due to disease or injury that was incurred or aggravated in service. 38 C.F.R. § 3.303(d) (2015). Service connection may be granted on a presumptive basis for a Persian Gulf Veteran who exhibits objective indications of qualifying chronic disability, including resulting from undiagnosed illness, that became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 21, 2016, and which by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C.A. § 1117 (West 2014); 38 C.F.R. § 3.317(a)(1) (2015). In claims based on qualifying chronic disability, unlike those for direct service connection, there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Gutierrez v. Principi, 19 Vet. App. 1 (2004). Notably, laypersons are competent to report objective signs of illness. A Persian Gulf Veteran is one who served in the Southwest Asia Theater of operations during the Persian Gulf War. 38 C.F.R. § 3.317 (2015). The Southwest Asia Theater of operations includes Iraq, Kuwait, Saudi Arabia, the neutral zone between Iraq and Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, the Gulf of Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea, the Red Sea, and the airspace above those locations. 38 C.F.R. § 3.317(d)(2) (2015). VA is authorized to pay compensation to any Persian Gulf veteran suffering from a qualifying chronic disability. A qualifying chronic disability for purposes of 38 U.S.C.A. § 1117 is a chronic disability resulting from (1) an undiagnosed illness, (2) a medically unexplained chronic multi-symptom illness (such as chronic fatigue syndrome, fibromyalgia, or irritable bowel syndrome) that is defined by a cluster of signs or symptoms, or (3), any diagnosed illness that the Secretary determines in regulation prescribed under 38 U.S.C.A. § 1117(d) (West 2014) warrants a presumption of service connection. 38 U.S.C.A. § 1117(a)(2) (West 2014); 38 C.F.R. § 3.317(a), (c) (2015). Objective indications of chronic disability include both signs, in the medical sense of objective evidence perceptible to a physician, and other, non-medical indicators that are capable of independent verification. To fulfill the requirement of chronicity, the illness must have persisted for a period of six months. 38 C.F.R. § 3.317(a)(2), (3) (2015). Signs or symptoms which may be manifestations of an undiagnosed illness or a chronic multisymptom illness include, but are not limited to: fatigue, signs or symptoms involving the skin, headache, muscle pain, joint pain, neurologic signs or symptoms, neuropsychological signs or symptoms, signs or symptoms involving the respiratory system (upper or lower), sleep disturbances, gastrointestinal signs or symptoms, cardiovascular signs or symptoms, abnormal weight loss, or menstrual disorders. If signs or symptoms have been medically attributed to a diagnosed (rather than undiagnosed) illness, the Persian Gulf War presumption of service connection does not apply. 38 C.F.R. § 3.317(b) (2015). Compensation shall not be paid under 38 C.F.R. § 3.317 for a chronic disability: (1) if there is affirmative evidence that the disability was not incurred during active military, naval, or air service in the Southwest Asia theater of operations; or, (2) if there is affirmative evidence that the disability was caused by a supervening condition or event that occurred between the veteran's most recent departure from active duty in the Southwest Asia theater of operations and the onset of the disability; or, (3) if there is affirmative evidence that the disability is the result of the veteran's own willful misconduct or the abuse of alcohol or drugs. 38 C.F.R. § 3.317(a)(7) (2015). In this case, the Veteran's service personnel records confirm that he had active service in the Southwest Asia Theater of operations during the Persian Gulf War. Specifically, his DD 214 shows participation in Operation Enduring Freedom from March 2002 to August 2002 and the Veteran has provided that he served onboard the U.S.S. Wasp throughout the Red Sea, the Arabian Sea and Gulf of Aden during this period. Because the Veteran served in the Southwest Asia Theater of operations during the Persian Gulf War, service connection may be established under 38 C.F.R. § 3.317 in this case. Residuals of Bilateral PFK Service treatment records notes that the Veteran underwent PRK in 2005. An August 2010 VA medical record reflects that the Veteran complained of halos since 2005, after undergoing PRK. He was assessed with nocturnal halos. An August 2010 VA primary care record notes that the Veteran reported being in Afghanistan with exposure to dust and sandstorms. In October 2010, the Veteran submitted a claim for VA compensation for an eye condition. In a November 2010 letter, the Veteran stated that he has a continuous halo effect that occurs at night and during rain like weather. He has been seen by VA and private eye doctors and was told that this issue was caused by the procedure that took place while he was on active duty. A December 2010 VA eye examination report reflects that the Veteran experienced extreme glare and halos at night and during inclement weather while he is driving. It is especially a problem when he is confronted by oncoming headlights and street lights. He had undergone photoreactive keratectomy to correct high myopia at Camp Lejeune in October 2004. This procedure was strongly recommended for certain military personnel who wore glasses. The examiner noted that the right eye visual symptoms included glare; impaired night vision; photophobia; and haloes. His left eye visual symptoms included glare; impaired night vision; and halos. The diagnosis was status post PRK symptomatology, halos at night. The VA examiner opined that the Veteran's disabling glare and halos at night and in poor weather are most likely caused by or a result of the PRK surgery he underwent at Camp Lejeune in 10/04. He stated that it is well-known that these are common post-operative symptoms of all kinds of refractive surgery. They are especially prevalent in PRK. In light of the above uncontradicted VA medical opinion, the Board finds that the Veteran has halos as a residual of PRK surgery in service. Therefore, service connection for residuals of PRK is warranted. IBS Service treatment records show that April 2002, the Veteran began taking Mefloquine doses. In August 2005, the Veteran was seen with complaints of headaches and nausea. When deployed personnel came back from Iraq, two out of three began to complain of flu like symptoms in his shop. He denied vomiting or diarrhea. From 2009 to 2010 the Veteran was seen on numerous occasions with complaints of abdominal pain. In a July 2014 letter, the Veteran asserted that since taking Mefloquine in 2002, he has had daily symptoms of loss of appetite, stomach cramps, diarrhea, and indigestion. The Veteran submitted a medical information form regarding possible side effects of Mefloquine that included gastrointestinal symptoms. In a December 2015 VA Gulf War examination report, the VA examiner opined that it is more likely than not that the Veteran's IBS, systemic muscle weakness, daily fatigue, and headaches (service connected ) constitute a Gulf War Syndrome diagnosis with medically unexplained symptoms due to environmental exposure in the Gulf including Mefloquine in 2002-2003. In a February 2016 medical opinion, a VA physician opined that the Veteran's IBS condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event or illness. The VA physician's rationale was that service treatment records were silent, his March 2010 claim for compensation was silent for any GI complaints or IBS, and there was no documentation of continuity of complaints/chronicity since military serration 5 years ago. She separately concluded that after a review of the PDR, Mefloquine does not cause IBS. In this case, the Board is aware of the negative February 2016 nexus opinion. However, IBS is on the list of medically unexplained chronic multisymptom illnesses subject to presumptive service connection. 38 C.F.R. § 3.317. Nexus evidence is not required. The evidence reasonably shows that the Veteran began having gastrointestinal symptoms in service, he has received a diagnosis of IBS related to those symptoms, and he is symptomatic to a degree of at least 10 percent and has been for over six months. Moreover, the Board finds no reason to question the Veteran's credibility with regard to these symptoms. Presumptive service connection is warranted for IBS, and the claim is granted. 38 C.F.R. § 3.317. Disability manifested by incoordination, excessive sweating, feeling faint, feeling weak, joint pain, low energy, muscle pain, muscle weakness In July 2014 written correspondence, the Veteran asserts that he suffers on a daily basis with a variety of symptoms, to include trouble focusing on thought processes, dizziness and being light headed, muscle pain, energy loss, muscle weakness, being uncoordinated at times, joint pain, excessive sweating, and feeling week. He asserts that these symptoms occurred after he was administered Mefloquine in 2002. In a December 2015 VA Gulf War examination report, it was noted that the Veteran reported symptoms of fatigue, muscle pain, and joint pain. The VA examiner opined that it is more likely than not that the Veteran's systemic muscle weakness and daily fatigue constitute a Gulf War Syndrome diagnosis with medically unexplained symptoms due to environmental exposure in the Gulf including Mefloquine in 2002-2003. In this case, the Board finds that the evidence is at least in equipoise with respect to the Veteran's claims of entitlement to service connection for a disability manifested by incoordination, excessive sweating, feeling faint, feeling weak, joint pain, low energy, muscle pain, muscle weakness. The Veteran's symptoms are chronic in that they have lasted for more than six months, and they have not been clearly attributed to a known clinical diagnosis. Indeed, sign or symptoms involving joint pain and muscle pain are among the signs or symptoms of an undiagnosed illness specifically listed in 38 C.F.R. § 3.317(b). Furthermore, the only medical opinion of record relates the Veteran's symptoms of systemic muscle weakness and daily fatigue to service. Therefore, resolving all doubt in favor of the Veteran, service connection for a disability manifested by symptoms of incoordination, excessive sweating, feeling faint, feeling weak, joint pain, low energy, muscle pain, muscle weakness is warranted as due to an undiagnosed illness; therefore, the claim is granted. Increased Rating Disability ratings are determined by application of the criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. Part 4 (2015). When a question arises as to which of two ratings applies under a particular Diagnostic Code (DC), the higher rating is assigned if the disability more closely approximates the criteria for the higher rating; otherwise, the lower rating applies. 38 C.F.R. § 4.7 (2015). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2015). The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where, as here, the question for consideration is the propriety of the initial rating assigned, evaluation of the medical evidence since the effective date of the grant of service connection and consideration of the appropriateness of "staged rating" (assignment of different ratings for distinct periods of time, based on the facts found) is required. See Fenderson v. West, 12 Vet. App. 119 (1999); see also Hart v. Mansfield, 21 Vet. App. 505 (2007). Service connection for ilioinguinal nerve damage as a residual of left inguinal hemiorrhaphy is assigned an initial noncompensable rating under the provisions of 38 C.F.R. § 4.124a, Diagnostic Code 8630 (2015). Under Diagnostic Code 8630, a noncompensable evaluation is assigned for mild to moderate paralysis of the ilio-inguinal nerve, whereas a 10 percent evaluation is warranted for severe to complete paralysis of that nerve. See 38 C.F.R. § 4.124a, Diagnostic Code 8630 (2015). Ilioinguinal neuritis characterized by loss of reflexes, muscle atrophy, sensory disturbances, and/or constant pain, at times excruciating, is to be evaluated on the scale provided for injury of the nerve involved, with a maximum equal to severe incomplete paralysis. The maximum evaluation which may be assigned for neuritis not characterized by organic changes is that provided for moderate incomplete paralysis. 38 C.F.R. §§ 4.123, 4.124a, Diagnostic Code 8630. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. An August 2009 service treatment record notes that he has ongoing left sided ilioinguila nerve pain. Previous trial of Neurontin without success and current trial of Lyrica is reported to be ineffective. A September 2009 service treatment record notes that the Veteran has ilioinguinal pain syndrome status post left inguinal hernia repair with subsequent pain. Steroid injections provided minimal improvement. Numbing sensation post shot was noted; however, pain returned in the morning after the injection. An August 2010 VA primary care record reflects that the Veteran complained of intermittent left low quadrant/inguinal region shooting/throbbing and pressure like discomfort/pain since left inguinal hernia repair in 2009. He is in persistent discomfort despite gabapentin and per the Veteran a local steroid injection worsened the pain in the past. On a scale from 0 to 10, his pain is a four to five. The assessment was chronic intermittent left inquinal/abdominal left lower quadrant pain that occasionally travels to the right lower abdominal quadrant. Question of mononeuritis multiplex from surgical complication. Despite evaluation and management in the past there is no clear etiology and no effective pain management. A September 2010 VA examination report reflects that the Veteran was diagnosed with left inguinal muscle spasm, status post-surgery, ilioinguinal neuropathy of the left inguinal area, and paresthesia and numbness of the left inguinal area. The Veteran indicated that this interferes with the daily activity of lifting. Nerves involved are the ilioinguinal nerve on the left which happened after the hernia surgery. Physical examination revealed that the disability is because of injury of the left ilioinguinal nerve and the neuritis and neuralgia without muscle wasting and atrophy of the ilioinguinal area, nerve damage of the ilioinguinal area. He has diminished pain, temperature, and touch sensation of the left inguinal area of ilioinguinal distribution. Active and passive range of motion including gravity against strong resistance within normal limits. Joints are not painful in motion. There is no additional limitation of pain, fatigue, weakness, lack of endurance, following there repetitive movements of the joint. The diagnosis was ilioinguinal nerve damage secondary to left inguinal herniorrhaphy. In an October 2010 letter, the Veteran stated that he has constant pain and numbness in his left hip and groin from the aftermath of the surgery for a hernia repair in 2009. His pain level is on average a 5 out of 10 and at its worst a 9 out of 10, which results in not being unable to walk or even stand. The scar from the surgery itches and for some reason feel hot at times, not to touch, but interior. When he sits, his legs start to have a tingle and have even gone numb as if they have the fallen asleep feeling. In a November 2010 letter, the Veteran asserted that he has severe pain on a daily basis, his legs give out on him and when he sits down, his legs go numb. His left hip and joint area constantly hurt him. An April 2013 VA peripheral nerves examination report reflects that the Veteran is diagnosed with ilioinguinal neuritis. The Veteran stated that since left inguinal hernia repair he has constant left medial thigh pain that feels "like lightning bolts', and anterior left thigh pain that feels like he was "hit with a hammer." Three to five times weekly he has left posterior thigh into left calf shooting pain that resolves spontaneously after a while, and leaves behind numbness. He also reports having constant tingling left foot pain. He receives no medication or treatment. The examiner noted that a review of x-rays of the pelvis, left hip and lumbar spine were all normal. Specific symptoms noted by the VA examiner was that the Veteran has tenderness over the left inguinal region. Muscle strength testing of the upper and the lower extremities revealed active movement against some resistance (4/5). Deep tendon reflexes were normal except for the right and left knees, which were indicated as absent. There was absent light touch and sharp response left toes, decreased response left foot, normal response left calf, absent response left knee, normal response distal left anterior knee, absent response medial and anterior thigh. There was tenderness over left inguinal region with normal sensation. The assessment was ilioinguinal neuritis causing left inguinal tenderness, sensory testing was non physiological, sensory deficits in left hand and left lower leg are unexplained by ilioinguinal neuritis. Upper and lower extremity weakness is not explained by ilioinguinal neuritis. X-rays of left hip, pelvis and lumbar spine rule out these regions as the cause of lower extremity sensory deficits and weakness. The Veteran had mild incomplete paralysis of the ilioinguinal nerve. The VA examiner further remarked that the Veteran's previous complaints of left hip and groin numbness were not repeated during this examination. His current report of left leg neuropathic type pain is not explained by ilioinguinal neuritis, and its etiology is unknown. There was no evidence of ilioinguinal muscle damage found. Despite the Veteran's assertions, the Board notes that the April 2013 VA examination report outweighs the Veteran's contentions. The Veteran is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses. Layno v. Brown, 6 Vet. App. 465 (1994). He is not, however, competent to identify a specific level of disability of his disability according to the appropriate diagnostic codes. On the other hand, such competent evidence concerning the nature and extent of the Veteran's ilioinguinal nerve damage disability has been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports and clinical records) directly address the criteria under which this disability is evaluated. Here, the clinical evidence pertaining to the Veteran's ilioinguinal nerve damage is more probative for the purposes of assigning a rating in conjunction with the relevant rating criteria and the Board finds that the pain and functional impairment reported has been appropriately considered in the currently assigned noncompensable rating in effect during the appeal period. Significantly, the April 2013 VA examiner opined that the Veteran had mild incomplete paralysis of the ilioinguinal nerve and that his current report of left leg neuropathic type pain was not explained by his service connected ilioinguinal neuritis. Even if his pain is constant and at time excruciating he does not display any of the other characteristics of severe paralysis of the ilio-inguinal nerve to warrant a higher 10 percent rating. The Board has carefully reviewed the rating schedule and finds no other diagnostic code that would provide a basis to grant an initial compensable rating. With regard to a postoperative left inguinal scar, the clinical evidence does not show that it currently is tender, painful, unstable or otherwise symptomatic such that a separate compensable rating would be warranted under 38 C.F.R. § 4118, DCs 7804 or 7805. While there is pain over the entire inguinal region, there is no evidence to indicate that the scar itself is the cause of such pain. In light of the above, the claim for an initial compensable rating for the Veteran's ilioinguinal nerve damage disability must be denied. In reaching this decision, the Board finds that the preponderance of the evidence is against the claim, and the claim must be denied. 38 U.S.C.A. § 5107(b) (West 2014); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board has also considered whether the Veteran's claim for a higher rating should be referred for consideration of an extraschedular evaluation pursuant to 38 C.F.R. § 3.321(b)(1) (2015) and has concluded that no such referral is warranted. The Veteran's symptoms are fully contemplated by the schedular rating criteria. A higher rating is available for ilioinguinal nerve damage; however the Veteran does not meet the criteria for a higher rating. There is nothing in the record to suggest that his disability picture is so exceptional or unusual as to render impractical the application of the regular schedular standards. Thun v. Peake, 22 Vet. App. 111 (2008). For these reasons, the disability picture is contemplated by the Rating Schedule, and the assigned schedular rating is adequate. Consequently, referral for extraschedular consideration is not required under 38 C.F.R. § 3.321(b)(1). ORDER Service connection for residuals of bilateral photo refractive keratectomy is granted. Service connection for IBS, claimed as loss of appetite, stomach cramps, diarrhea, indigestion, and cramps, is granted. Service connection for a disability manifested by incoordination, excessive sweating, feeling faint, feeling weak, joint pain, low energy, muscle pain, muscle weakness, is granted. Entitlement to an initial compensable rating for ilioinguinal nerve damage as a residual of left inguinal hemiorrhaphy is denied. REMAND With regard to the claim for service connection for a right wrist disability, service treatment records include a chronic problem list that includes unspecified muscle strain. On self-report of medical history in January 2010, the Veteran indicated he had numbness or tingling. An examiner noted that the Veteran had intermittent right wrist pain. In March 2010, the Veteran submitted a claim for VA benefits for wrist numbness. A September 2010 VA examination report reflects that the Veteran complained of right wrist pain. Flexion and extension to 80 degrees, 70 degrees without pain. Ulnar deviation/ radial deviation 30 degrees and 20 degrees without tenderness. Abduction and adduction of the fingers are normal. X-ray of the right wrist shows no evidence of bony or joint abnormalities. In an October 2010 letter, the Veteran stated that his right wrist goes numb at least once a week, and that numbness stretches to his hand and fingers. The Veteran underwent an April 2013 VA wrist examination and the examination report reflects that the Veteran has never been diagnosed with a wrist disability. The Veteran reported the onset of right lateral and posterior wrist numbness while active duty. There was no injury or surgery. He currently has one to two times weekly episodes of sharp shooting pain in the right wrist, extending into the fingers, and lasting one to two 2 hours. The assessment was intermittent right wrist pain. No chronic diagnosis. The Veteran underwent an additional VA hand and finger examination in December 2015. The examiner determined that there was no diagnosed right hand disability. The Veteran complained of right wrist numbness lasting a few hours, three to four days a week. Neurology noted possible carpal tunnel, but at present there was no working diagnosis. Range of motion testing was normal. The Board finds, that given the Veteran's military history of serving in Southwest Asia and his history of right wrist complaints with no confirmed diagnosis, an additional examination to determine whether his right wrist disorder is due to an illness associated with Persian Gulf War service is warranted. Also, as noted above, the Veteran has asserted that he is unable to maintain substantially gainful employment due to service-connected disabilities. See December 2010 VA eye examination report. A TDIU claim is part of an increased rating claim when a TDIU claim is raised by the record. Thus, in this case, the issue of entitlement to a TDIU is properly before the Board. Rice v. Shinseki, 22 Vet. App. 447 (2009). The duty to assist requires that VA obtain an examination that includes an opinion on what effect a veteran's service-connected disability has on his ability to work. Friscia v. Brown, 7 Vet. App. 294, 297 (1994). Accordingly, a remand is warranted to obtain an opinion with respect to the effects of his service connected disabilities on his ability to secure and follow a substantially gainful occupation. The Veteran should also be sent a VCAA letter specifically notifying him of the information and evidence necessary to substantiate entitlement to TDIU. See 38 C.F.R. § 3.159(b)(1)(2015). Accordingly, the case is REMANDED for the following actions: 1. Request the Veteran to complete a formal application for a TDIU (VA Form 21-8940), and provide proper notice of the evidence and information necessary to substantiate a TDIU claim. 2. Schedule the Veteran for a VA examination, by an examiner with the appropriate expertise, to determine the nature and etiology of his right wrist disability. The claims file, to include a copy of this remand, must be made available to and be reviewed by the examiner, and the examination report should note that review. All indicated tests and studies shall be conducted. The examiner should identify all current diagnoses referable to the right wrist. In this regard, s/he should specifically state whether the symptoms related to Veteran's right wrist are attributed to a known clinical diagnosis. If no diagnosis of the right wrist is found, such should be stated. (a) For each currently diagnosed right wrist disorder, the examiner should render an opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that such had its onset during the Veteran's active duty service or is otherwise related to such service. (b) If Veteran's right wrist symptoms cannot be ascribed to any known clinical diagnosis, specify whether the Veteran has objective indications of a chronic disability resulting from an undiagnosed illness, as established by history, physical examination, and laboratory tests, that has either (1) existed for 6 months or more, or (2) exhibited intermittent episodes of improvement and worsening over a 6-month period. A full and complete rationale for all opinions expressed must be provided 3. Then, schedule the Veteran for a VA examination, by an examiner with the appropriate expertise, to determine whether his service-connected disabilities prevent him from securing and following employment for which his education and occupational experience would otherwise qualify him. The claims file, to include a copy of this remand, must be made available to and be reviewed by the examiner, and the examination report should note that review. All indicated tests and studies shall be conducted. The AOJ should ensure that the VA examiner is informed of each disability for which service connection has been granted to date, to include those granted in the decision above. The examiner is requested to opine as to the impact of the Veteran's service-connected disabilities on his employability. A full and complete rationale for all opinions expressed must be provided. 4. Then, readjudicate the claims for entitlement to a right wrist disability and entitlement to a TDIU. If any decision is adverse to the Veteran, issue a supplemental statement of the case and allow the appropriate time for response. Then, return the case to the Board. The appellant 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 case 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 2014). ______________________________________________ THOMAS H. O'SHAY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs