Citation Nr: 18145748 Decision Date: 10/30/18 Archive Date: 10/30/18 DOCKET NO. 15-23 867 DATE: October 30, 2018 ORDER Entitlement to service connection for sleep apnea is granted. Entitlement to service connection for left lower extremity radiculopathy is denied. Entitlement to service connection for right lower extremity radiculopathy is denied. Entitlement to service connection for a right shoulder condition due to undiagnosed illness is denied. Entitlement to an initial rating in excess of 10 percent for insomnia is denied. REMANDED Entitlement to service connection for a right thumb disability is remanded. Entitlement to service connection for a right knee condition, to include as due to an undiagnosed illness, is remanded. Entitlement to service connection for a left knee condition, to include as due to an undiagnosed illness, is remanded. Entitlement to service connection for a left foot condition, to include as due to an undiagnosed illness, is remanded. Entitlement to service connection for a finger condition, to include as due to an undiagnosed illness, is remanded. Entitlement to service connection for a neurological condition, to include as due to an undiagnosed illness, is remanded. Entitlement to a rating in excess of 10 percent for right shoulder bursitis is remanded. Entitlement to an initial rating in excess of 10 percent for Dequervain's tenosynovitis of the left thumb is remanded. Entitlement to a rating in excess of 10 percent for low back disability is remanded. Entitlement to a rating in excess of 20 percent for metatarsalgia of the right foot is remanded. Entitlement to an initial compensable rating for hypertension is remanded. Entitlement to an initial rating in excess of 10 percent for carpal tunnel syndrome (CTS) of the right wrist is remanded. Entitlement to an initial rating in excess of 10 percent for CTS of the left wrist is remanded. FINDINGS OF FACT 1. Resolving all reasonable doubt in his favor, the Veteran’s sleep apnea is related to his active service. 2. The preponderance of the competent evidence of record is against a finding that the Veteran has left lower extremity radiculopathy. 3. The preponderance of the competent evidence of record is against a finding that the Veteran has right lower extremity radiculopathy. 4. The Veteran does not have an undiagnosed illness manifested by right shoulder pain; right shoulder pain is a symptom of service-connected right shoulder bursitis. 5. For the entire period of the appeal, the Veteran’s insomnia has been manifested by sleep disturbance; at no time have the symptoms been manifested by impairment greater than occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress. CONCLUSIONS OF LAW 1. The criteria for service connection for sleep apnea are met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303. 2. The criteria for service connection for left lower extremity radiculopathy have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310. 3. The criteria for service connection for right lower extremity radiculopathy have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310. 4. The criteria for service connection for a right shoulder condition due to undiagnosed illness have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.317. 5. An initial rating in excess of 10 percent for the Veteran’s insomnia is not warranted. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9410. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 1980 to March 2000, to include service in Southwest Asia. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active duty. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may be established on a secondary basis for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Service connection may also 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, 2021, and which by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C. § 1117; 38 C.F.R. § 3.317(a)(1). To determine whether the undiagnosed illness is manifested to a degree of 10 percent or more the condition must be rated by analogy to a disease or injury in which the functions affected, anatomical location, or symptomatology are similar. See 38 C.F.R. § 3.317(a)(5); see also Stankevich v. Nicholson, 19 Vet. App. 470 (2006). A “qualifying chronic disability” for purposes of 38 U.S.C. § 1117 is a chronic disability resulting from (1) an undiagnosed illness, (2) a medically unexplained chronic multisymptom illness (such as chronic fatigue syndrome (CFS), 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. § 1117(d) warrants a presumption of service connection. 38 U.S.C. § 1117(a)(2); 38 C.F.R. § 3.317(a), (c). “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). Signs or symptoms that may be manifestations of undiagnosed illness include, but are not limited to, the following: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurologic signs or symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the respiratory system (upper or lower); (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; (12) abnormal weight loss; and (13) menstrual disorders. 38 C.F.R. § 3.317(b). In order to prevail on the issue of service connection, there must be medical evidence of a (1) current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. Hickson v. West, 12 Vet. App. 247, 253 (1999). The existence of a current disability is the cornerstone of a claim for VA disability compensation. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Lay statements may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C. § 1153(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed Cir. 2007). Although lay persons are competent to provide opinions on some medical issues, some medical issues fall outside the realm of common knowledge of a lay person. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). With an approximate balance of positive and negative evidence on a relevant issue, VA resolves reasonable doubt in the claimant’s favor. 38 U.S.C.§ 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518 (1996). Sleep Apnea The Veteran claims that his sleep apnea had its onset in service and has continued since that time. See December 2014 Notice of Disagreement, May 2015 VA Form 9 and September 2015 statement from the Veteran. May 2014 lay statements submitted by the Veteran’s wife, ex-wife, and a person with whom he served describe his history of loud snoring, gasping for air and pauses in breathing during sleep, and daytime sleepiness since service. The Veteran’s service treatment records (STRs) do not reflect a diagnosis of or specific treatment for sleep apnea. However, in a September 2015 statement, the Veteran explained that he did not seek medical treatment very often in service for fear of being discharged early. That the Veteran has a current diagnosis of sleep apnea is not in dispute. See September 2013 VA sleep study. Thus, the current disability requirement is met. As for the nexus element of a service connection claim, the record establishes that, since 2013, the Veteran has credibly and consistently maintained that he has had sleep apnea since service. His statements, as well as those from his wife, ex-wife and fellow service member, who all lived or worked with him during his military service, establish continuous and chronic symptoms of sleep apnea since service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303 (a); Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); Charles v. Principi, 16 Vet. App. 370 (2002). They are all credible to speak to the onset of the Veteran’s sleep problems. Resolving all doubt in the Veteran’s favor, service connection for sleep apnea is granted. See 38 C.F.R. § 3.102; Gilbert, supra. Left and Right Lower Extremity Radiculopathy The Veteran maintains that he has left lower extremity radiculopathy and right lower extremity radiculopathy secondary to his service-connected low back disability. Review of the record, however, does not show the presence of these disabilities. Additionally, a June 2011 VA examination report notes that the examiner opined the Veteran had no objective findings of lower extremity radiculopathy. There is no medical or other competent evidence to the contrary. Thus, the Board concludes that the weight of the competent and credible evidence establishes that the Veteran has not been shown to have current left lower extremity radiculopathy or right lower extremity radiculopathy. See Brammer v. Derwinski, supra. With regard to the Veteran’s contentions that he has current lower extremity radiculopathy, the Board acknowledges that he is competent to describe his symptoms and observations. However, he is not competent to opine as to medical diagnosis or etiology of a disorder in these matters; these are questions medical in nature and not capable of resolution by lay observation. See Jandreau v. Nicholson, supra. In sum, the most competent and credible evidence of record establishes that the Veteran has not been shown to have current left lower extremity radiculopathy or right lower extremity radiculopathy. Thus, the Board must conclude that the preponderance of the evidence is against the claims, the benefit-of-the-doubt rule does not apply, and the claims for service connection must be denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. Right Shoulder Condition Due to Undiagnosed Illness In this case, the weight of the evidence does not show that the Veteran has a qualifying chronic disability in the right shoulder (other than for what he is already service-connected), to include an undiagnosed illness and medically unexplained chronic multisymptom illness. Instead, the record reflects that all symptoms asserted to be attributable to an undiagnosed illness are considered part of the Veteran’s already service-connected disability. Specifically, the Veteran has no condition manifested by right shoulder muscle and joint pain apart from his service-connected bursitis. See June 2011 VA examination report. Therefore, the criteria for service connection for a right shoulder condition due to an undiagnosed illness are not met, and the appeal must be denied. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.14 (providing that rating the same disability under different diagnostic codes is prohibited as pyramiding); Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Rating for Insomnia Disability evaluations are determined by application of the VA Schedule for Rating Disabilities, which is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Each disability must be viewed in relation to its history and there must be emphasis upon the limitation of activity imposed by the disabling condition. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the appellant working or seeking work. 38 C.F.R. § 4.2. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. Where entitlement to compensation has been established and a higher initial disability rating is at issue, the level of disability at the time entitlement arose is of primary concern. Consideration must also be given to a longitudinal picture of the veteran’s disability to determine if the assignment of separate ratings for separate periods of time, a practice known as “staged” ratings, is warranted. Fenderson v. West, 12 Vet. App. 119 (1999). Staged ratings are appropriate in any increased rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran’s service-connected insomnia is currently rated at 10 percent under 38 C.F.R. § 4.130, Diagnostic Code 9410, other specified anxiety disorder. Under these criteria, a 10 percent rating is warranted when the disorder is manifested by occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication. See 38 C.F.R. § 4.130, Diagnostic Code 9410. A 30 percent rating is warranted when the disorder is manifested by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). Id. A 50 percent rating is warranted where the psychiatric condition produces occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is warranted where the psychiatric condition produces occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. Id. A 100 percent rating is warranted where the psychiatric condition results in total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation or own name. Id. Evaluation under § 4.130 is symptom-driven, meaning that symptomatology should be the fact-finder’s primary focus when deciding entitlement to a given disability rating under that regulation. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013). In Vazquez-Claudio, the United States Court of Appeals for the Federal Circuit explained that the frequency, severity and duration of the symptoms also play an important role in determining the rating. Id. at 117. Significantly, however, the list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the rating, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific rating. 38 C.F.R. § 4.21; Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). If the evidence shows that the Veteran suffers symptoms listed in the rating criteria or symptoms of similar severity, frequency, and duration, that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the criteria for a particular rating, the appropriate equivalent rating will be assigned. Mauerhan, 16 Vet. App. at 443; see also Vazquez-Claudio, 713 F.3d at 117. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Here, the medical evidence shows that the impairment from the Veteran’s insomnia more nearly approximates occupational and social impairment due to mild transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, contemplated by a 10 percent rating, rather than the occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and normal conversation) required for a 30 percent evaluation. The March 2012 VA examiner opined that the Veteran’s condition caused only mild difficulties in his vocational function. The Veteran had been working full-time for three years. He reported no problems initiating sleep (with medication) but had some difficulty maintaining sleep, waking three to four times per night because of back pain. He denied any other psychiatric symptoms. This evidence supports a 10 percent rating, but no higher, as there is no evidence of intermittent periods of inability to perform occupational tasks at any time. Instead, as described above, the Board finds that the Veteran’s insomnia disability picture is one consistent with approximates occupational and social impairment due to mild transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress. The preponderance of the evidence is against this claim; therefore, the appeal in the matter of a higher initial rating for insomnia must be denied. REASONS FOR REMAND Service Connection for Conditions Due to Undiagnosed Illness As noted above, the Veteran is a Persian Gulf War veteran and qualifies for consideration for presumptive service connection for disabilities resulting from undiagnosed illness or medically unexplained chronic multisymptom illness. He maintains that he has a finger condition related to service, to include as due to undiagnosed illness. He underwent a VA fibromyalgia examination in August 2012, but no such disability was found. No explanation was provided for the Veteran’s finger complaints. Thus, the Board finds that a supplemental medical opinion is needed as to whether the Veteran’s claimed finger signs and symptoms are due to an undiagnosed illness or medically unexplained chronic multisymptom illness, or due to a diagnosed condition that may be related to service. The Veteran also maintains that he has neurological conditions related to service, to include as due to undiagnosed illness. He underwent a VA examination in August 2012; however, the opinion is not adequate for adjudication purposes. In this regard, the Veteran reported symptoms of memory loss, headaches and dizziness since service. The examiner stated that there was no diagnosis of a neurological disability. Headaches were explained by sleep deprivation, which could also affect memory. Dizziness was thought to be vasovagal or orthostatic. No nexus opinions or discussion of undiagnosed illness was provided. Thus, the Board finds that a supplemental medical opinion is needed as to whether the Veteran’s claimed neurological signs and symptoms are due to an undiagnosed illness or medically unexplained chronic multisymptom illness, or due to a diagnosed condition that may be related to service. Ratings for Right Shoulder Bursitis and Low Back Disability The Board finds the VA shoulder and back examinations and opinions obtained in September 2012 to be inadequate. Specifically, the United States Court of Appeals for Veterans Claims (Court) found the final sentence of 38 C.F.R.§ 4.59 requires that VA examinations include joint testing for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. See Correia v. McDonald, 28 Vet. App. 158 (2016). After obtaining updated treatment records, the Veteran should be scheduled for new VA examinations. Service Connection for Right Thumb Disability and Ratings for Dequervain's Tenosynovitis of the Left Thumb, CTS of the Right Wrist and Left Wrist Regarding the Veteran’s claims for service connection for a right thumb disability and increased ratings for service-connected left thumb disability and CTS disabilities, the Veteran underwent VA examinations for all these disabilities in June 2011. However, these examination reports are inadequate for adjudication purposes because the examiners never reviewed the claims file in conjunction with the examinations. See Green v. Derwinski, 1 Vet. App. 121 (1991). Moreover, regarding the right thumb claim, the Veteran maintains that he has a right thumb disability related to service or secondary to service-connected CTS. The June 2011 VA examiner failed to provide a direct service connection opinion. The examiner did opine that the Veteran’s right thumb disability is less likely than not related to his CTS; however, this language does not adequately address whether a nonservice-connected disability was aggravated by a service-connected disability. See generally, El Amin v. Shinseki, 26 Vet. App. 136, 140 (2013); Allen v. Brown, 7 Vet. App. 439, 448 (1995). On remand, these inadequacies should be corrected. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Service Connection for Left Foot, Right Knee, and Left Knee Conditions; and Ratings for Hypertension and Metatarsalgia Right Foot The Veteran most recently underwent a VA hypertension examination in March 2012. Treatment notes dated subsequent to this examination show higher blood pressure readings. See 2018 VA treatment records. Given the evidence and assertions of worsening symptoms, a current VA medication examination regarding the severity of his hypertension disability is needed. 38 C.F.R. §§ 4.1, 4.2; See Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). The Veteran underwent a VA examination to assess the severity of his service-connected right foot metatarsalgia in September 2012. In conjunction with other claims, he underwent additional VA foot examinations in 2015 and 2018. These examination reports contain information pertinent to the right foot metatarsalgia and left foot condition claims. Additionally, the Veteran underwent a knee examination in July 2018. Notably, a Supplemental Statement of the Case (SSOC) was not issued after the completion of the 2015 and 2018 VA foot examinations, 2018 knee examination, and receipt of the 2018 VA hypertension treatment records. Moreover, no waiver of Agency of Original Jurisdiction is of record. See 38 C.F.R. § 19.31. Thus, a remand is also required to issue an SSOC for these issues. The matters are REMANDED for the following actions: 1. Contact the Veteran and ask that he identify the provider(s) of any additional treatment or evaluation he has received for the conditions at issue, and to provide any releases necessary for VA to secure such records of treatment or evaluation. 2. Obtain complete records of all such treatment or evaluation from all sources identified by the Veteran.] 3. After the above records development is completed, schedule the Veteran for a VA examination to determine the current severity of his service-connected right shoulder disability. The claims file must be made available to and reviewed by the examiner prior to the examination. All necessary tests should be conducted and the examiner should review the results of any testing prior to completion of the report. The examination must be conducted in accordance with the current disability benefits questionnaire or examination worksheet applicable to the disability. Ranges of motion in active motion, passive motion, weight-bearing, and nonweight-bearing, for the right shoulder must be conducted. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. The examiner must also provide an opinion concerning the functional impairment of the Veteran’s service-connected right shoulder disability. The examiner must provide a detailed rationale for any opinion expressed. If an opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e. no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e. additional facts are required, or the examiner does not have the needed knowledge or training). 4. After the above records development is completed, schedule the Veteran for a VA examination to determine the current severity of his service-connected low back disability. The claims file must be made available to and reviewed by the examiner prior to the examination. All necessary tests should be conducted and the examiner should review the results of any testing prior to completion of the report. The examination must be conducted in accordance with the current disability benefits questionnaire or examination worksheet applicable to the disability. Ranges of motion in active motion, passive motion, weight-bearing, and nonweight-bearing, for the low back must be conducted. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. The examiner must also provide an opinion concerning the functional impairment of the Veteran’s service-connected low back disability. The examiner must provide a detailed rationale for any opinion expressed. If an opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e. no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e. additional facts are required, or the examiner does not have the needed knowledge or training). 5. After the above records development is completed, schedule the Veteran for a VA examination to determine the current severity of his service-connected hypertension. The claims file should be made available to the examiner for review prior to the examination. All indicated studies should be performed. All symptoms should be reported and any functional impairment noted. An explanation for all opinions expressed must be provided. The examiner must utilize the appropriate Disability Benefits Questionnaire. 6. After the above records development is completed, schedule the Veteran for a VA examination to determine the current severity of his service-connected Dequervain’s tenosynovitis of the left thumb. The claims file should be made available to the examiner for review prior to the examination. All indicated studies should be performed. All symptoms should be reported and any functional impairment noted. An explanation for all opinions expressed must be provided. The examiner must utilize the appropriate Disability Benefits Questionnaire. 7. After the above records development is completed, schedule the Veteran for a VA examination to determine the current severity of his service-connected CTS of the right wrist and CTS of the left wrist. The claims file should be made available to the examiner for review prior to the examination. All indicated studies should be performed. All symptoms should be reported and any functional impairment noted. An explanation for all opinions expressed must be provided. The examiner must utilize the appropriate Disability Benefits Questionnaire. 8. Forward the Veteran’s claims file to an appropriate VA examiner who must review the claims file (to include this remand) and provide an addendum opinion as to a) whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s right thumb disability is etiologically related to his service; and b) whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s service-connected CTS caused the Veteran’s right thumb disability or aggravated the right thumb disability. For the purposes of secondary service connection, the examiner is advised that aggravation is defined as “any increase in disability.” See Allen v. Brown, 7 Vet. App. 439, 448 (1995). If the examiner determines that the requested opinion may not be provided without a physical examination of the Veteran, then such should be scheduled. A complete rationale must be provided for all opinions presented. If the examiner cannot provide the requested opinion without resorting to speculation, he or she should provide an explanation stating why this is so. In so doing, the examiner should explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. 9. After all available records are associated with the claims file, schedule the Veteran for an appropriate VA examination or examinations to determine the nature and probable etiology of any finger and neurological conditions, to include dizziness, memory loss and headaches. The examiner should conduct any necessary testing to rule out a diagnosis for the claimed signs and symptoms. The examiner should characterize the Veteran’s finger and neurological symptoms/conditions as belonging to one of these disability patterns: (1) undiagnosed illness, (2) a diagnosable but medically unexplained chronic multisymptom illness of unknown etiology, or (3) a disease with a clear and specific etiology. With regard to any diagnosed finger and neurological disabilities, the examiner should opine as to whether it is at least as likely as not (50 percent or greater probability) that any current disability is related to service or secondary to service-connected disability. Any opinions expressed by the examiner must be accompanied by a complete rationale. A. ISHIZAWAR Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD K.R.Fletcher, Counsel