Citation Nr: 18147188 Decision Date: 11/02/18 Archive Date: 11/02/18 DOCKET NO. 16-26 240 DATE: November 2, 2018 REMANDED The issue of entitlement to service connection for right wrist disability is remanded. The issue of entitlement to service connection for back condition is remanded. The issue of entitlement to service connection for chronic sinusitis is remanded. The issue of entitlement to service connection for allergic rhinitis is remanded. The issue of entitlement to service connection for skin disorder, to include dermatitis and urticaria is remanded. REASONS FOR REMAND The Veteran served on active duty from February 1998 to September 2003. He had a prior duty period from March to August 1996. The Veteran testified before the undersigned Veterans Law Judge during an October 2016 Travel Board hearing; a transcript is of record. The Board notes that the issue related to right wrist arthralgia has been recharacterized as “a right wrist disability.” See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (when a claimant makes a claim, he is seeking service connection for symptoms regardless of how those symptoms are diagnosed or labeled). In addition, the Veteran’s claim for service connection for dermatitis has been combined with the issue of urticaria to afford the Veteran the broadest possible scope for his claim of entitlement to service connection for a skin disorder. Clemons, at 6. 1. Right wrist disability An August 1998 service treatment record notes that the Veteran complained of pain and locking up of his right wrist. Most recently, the Veteran reports limited range of motion, pain with constant locking and popping, and occasional stiffness in his right wrist; he stated at the Board hearing that he has arthritis. See, e.g., April 2014 Wrist Conditions DBQ filled out by Dr. Reddy; October 2016 Board hearing transcript. Dr. Reddy reports in the April 2014 DBQ that imaging studies of the wrist had been performed. Dr. Reddy notes that even though arthritis was not documented, the right wrist was “abnormal” and that there is some indication in the imaging that might be due to “old injury.” This imaging study of the Veteran’s wrists mentioned in the April 2014 DBQ is, however, not associated with the Veteran’s claims file, and the Board is unable to determine whether the Veteran has a current diagnosis of a right wrist disability. Upon remand, the AOJ must obtain the result of the imaging study of his wrists mentioned by Dr. Reddy in April 2014 and schedule the Veteran a VA medical examination to ascertain the current diagnosis and etiology of his right wrist disability. 2. Back condition The Veteran’s service treatment records indicate that the Veteran was treated for his low back pain in service on multiple occasions. At the October 2016 Board hearing, the Veteran testified that he injured his back while he was lifting a heavy generator. The medical evidence of record indicate that he was diagnosed with lumbosacral spondylosis and sacroiliitis and had gotten an injection in the area to relieve the pain. See November 2010 Scott & White treatment record. An April 2014 VA treatment record indicates that the Veteran complained chronic low back pain radiating to lower back and legs with numbness and tingling. A February 2015 VA neurosurgery consult note indicates that the Veteran was assessed with degenerative lumbar disc disease and left radiculopathy. The Veteran maintains that his back condition is related to his service, in particular, to the injury from lifting a heavy generator. See, e.g., October 2016 Board hearing. Upon remand, the AOJ must schedule the Veteran for a VA medical examination to ascertain the current diagnosis and etiology of his back condition. 3. Chronic sinusitis The January 1998 enlistment examination indicates that the Veteran reported to have had sinusitis, and that he had just finished taking medications for sinus condition in January 1998. A September 2016 VA medical opinion stating that it was less likely than not that the Veteran’s sinusitis, which existed prior to his service, was permanently aggravated or worsened by service because no episode of sinusitis was documented post service. Also of record is a November 2016 private medical record indicates that the Veteran has been treated for chronic sinus infection and rhinitis with medications. The Board finds that the September 2016 VA medical opinion is inadequate for rating purposes since it is based on review of all available records. Upon remand, the AOJ must obtain relevant treatment records from Baylor Scott & White Medical Center and request an addendum opinion for aggravation of his sinusitis. 4. Allergic rhinitis A February 2003 service treatment record indicates that the Veteran was treated for rhinitis. A November 2009 private treatment record shows that the Veteran was treated for allergic rhinitis. A September 2016 VA medical opinion concludes that the Veteran’s rhinitis in service was acute and infectious, and not allergic, in part, because there is no objective clinical record showing treatment of allergic rhinitis before his 2014 visit to VA. Also of record is a November 2016 private treatment record, where the doctor noted that the Veteran’s chronic rhinitis had led him to getting chronic sinus infections. The Board finds that the September 2016 VA medical opinion is inadequate for rating purposes because it is based on incomplete information on the Veteran’s post service rhinitis treatments. And the November 2016 treatment record indicates that his rhinitis and sinusitis may be etiologically related. Upon remand, the AOJ must obtain relevant treatment records from Baylor Scott & White Medical Center and request an addendum opinion for the etiology of his allergic rhinitis. 5. Skin disorder, to include dermatitis and urticaria A March 2000 service treatment record reports pruritic rash on his foot bilaterally and the Veteran was diagnosed with dyshidrotic eczematous dermatitis. A January 2001 service treatment record indicates that the Veteran was seen for rash on hands and arms lasting for three months. He was diagnosed to have tinea corporis on his right arm. A November 2016 private treatment record indicates that the Veteran complained recurrent rash on hands. The Veteran reported that steroid cream does nothing, but the condition resolves. Upon remand, the AOJ must obtain pertinent treatment records from Baylor Scott & White Medical Center and request an addendum medical opinion concerning the etiology of the indicated rash on hands. The matters are REMANDED for the following action: 1. Obtain all outstanding private and VA medical records, to include any imaging studies in the records concerning the Veteran’s wrist condition. Ask the Veteran to complete a VA Form 21-4142 for Baylor Scott & White Medical Center and/or any other private facilities where he sought treatment for his back, wrist, sinusitis, rhinitis, and skin condition after his discharge. Make two requests for the authorized records, unless it is clear after the first request that a second request would be futile. All attempts to obtain records should be documented in the claims folder. 2. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any wrist and or back disability. The examiner must opine whether any disorder found it is at least as likely as not related to an in-service injury, event, or disease, including injury from lifting a heavy generator. 3. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s chronic sinusitis is at least as likely as not aggravated beyond its natural progression by service or is otherwise related to service. 4. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s allergic rhinitis is at least as likely as not due to his service or is chronic from pathology noted in service.   5. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s skin condition, to include rash on hands, is at least as likely as not related to his service or occurrence or event therein. MICHAEL D. LYON Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Y. Taylor, Associate Counsel