Citation Nr: 18155901 Decision Date: 12/06/18 Archive Date: 12/06/18 DOCKET NO. 14-34 541A DATE: December 6, 2018 ORDER Entitlement to an initial compensable rating of 20 percent for residuals of superior labral tear from anterior to posterior (SLAP) of the right (dominant) shoulder is granted, effective June 16, 2015. Entitlement to an initial compensable rating of 10 percent for irritable bowel syndrome (IBS) for the period prior to June 1, 2016 is granted. Entitlement to an initial compensable rating of 10 percent for chronic interstitial cystitis is granted. Entitlement to an initial compensable rating of 10 percent for endometriosis is granted. Entitlement to an initial compensable rating of 30 percent for migraine headaches prior to November 21, 2017, and of 50 percent therefrom, is granted. Entitlement to an initial compensable rating for carpal tunnel syndrome (CTS), right (dominant) hand for the period prior to November 21, 2017 is denied. REMANDED Entitlement to an initial rating higher than 10 percent for IBS for the period June 1, 2016 forward is remanded. Entitlement to an initial compensable rating for right CTS for the period November 21, 2017 forward is remanded. FINDINGS OF FACT 1. The preponderance of the evidence of record shows that prior to June 16, 2015 the right shoulder manifested with full, pain-free range of motion (ROM). The evidence is in equipoise as to whether from June 16, 2015 it was ascertainable that the right shoulder manifested with noncompensable limitation of motion (LOM) and with pain and weakness. 2. The preponderance of the evidence of record shows that for the period prior to June 1, 2016, the Veteran’s IBS manifested with moderate severity. 3. The preponderance of the evidence of record shows that the Veteran’s chronic interstitial cystitis has more nearly approximated the need for long-term drug therapy throughout the rating period on appeal. 4. The preponderance of the evidence of record shows that the Veteran’s endometriosis manifests with the need for continuous treatment to prevent pelvic pain and bleeding throughout the rating period on appeal. 5. The evidence of record is at least in equipoise as to whether the Veteran’s migraine headaches manifests with characteristic prostrating attacks occurring on average once a month over the last several months up to November 21, 2017, and from that point forward are manifested by very frequent completely prostrating headaches. 6. The preponderance of the evidence of record shows that for the period prior to November 21, 2017, the Veteran’s CTS, right hand, was asymptomatic. CONCLUSIONS OF LAW 1. The criteria for entitlement to an initial compensable rating for residuals of SLAP, right (dominant) shoulder for the period prior to June 16, 2015 have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.10, 4.31, 4.71a, Diagnostic Code (DC) 5201. 2. Resolving all reasonable doubt in the Veteran’s favor, the criteria for an initial rating of 20 percent for residuals of SLAP, right (dominant) shoulder, have been met as of June 16, 2015. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.400, 4.1, 4.3, 4.10, 4.40, 4.45, 4.59, 4.71a, DC 5201. 3. The criteria for an initial compensable rating of 10 percent for IBS for the period prior to June 1, 2016 have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.10, 4.114, DC 7319. 4. The criteria for an initial compensable rating of 10 percent for chronic interstitial cystitis have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.10, 4.115a. 5. The criteria for an initial compensable rating of 10 percent for endometriosis have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.10, 4.116, DC 7629. 6. Resolving all reasonable doubt in the Veteran’s favor, the criteria for an initial compensable rating of 30 percent migraine headaches have been met prior to November 21, 2017, and for a 50 percent rating from that date forward. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.10, 4.124a, DC 8100. 7. The criteria for an initial compensable rating for CTS, right (dominant) hand for the period prior to November 21, 2017 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.31, 4.124a, DC 8599-8515. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Increased Rating Applicable Law and Regulation Disability ratings are determined by the application of the Schedule for Rating Disabilities, which assigns evaluations based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; see also Peyton v. Derwinski, 1 Vet. App. 282 (1991). In general, the degree of impairment resulting from a disability is a factual determination and generally the Board’s primary focus in such cases is upon the current severity of the disability. Francisco v. Brown, 7 Vet. App. 55, 57-58 (1994). Nonetheless, separate, or staged, ratings can be assigned for separate periods during the rating period on appeal based on the facts found as concerns the severity of the disability. See O’Connell v. Nicholson, 21 Vet. App. 89, 91-92 (2007); Fenderson v. West, 12 Vet. App. 119 (1999). 1. Entitlement to an initial compensable rating for SLAP of the right shoulder In addition to the general rating principles set forth above, the intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize painful, unstable, or malaligned joints due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. The Court of Appeals for Veterans Claims has held that the final sentence of § 4.59 creates a requirement that certain range of motion and other testing be conducted whenever possible in cases of joint disabilities. Rating Criteria Disabilities of the shoulder and arm are rated under Diagnostic Codes 5200 through 5203. A distinction is made between major (dominant) and minor upper extremities for rating purposes. In the instant case, the examination reports reflect that the Veteran is right-handed, which means that his disabled shoulder is the major, or dominant, shoulder. The applicable criteria for the major side provide that shoulder motion limited to 25 degrees from the side warrants the maximum, 40 percent rating; motion limited to midway between the side and shoulder level warrants a 30 percent rating; and, motion to shoulder level warrants a 20 percent rating. 38 C.F.R. § 4.71a, DC 5201. Normal ROM for the shoulder is 0 to 180 degrees for forward flexion (elevation) and abduction; and, 0 to 90 degrees for internal and external rotation. See 38 C.F.R. § 4.71a, Plate I. Discussion The examination report (08/11/2011 VA Examination, 2nd Entry) reflects the Veteran’s report that her right shoulder disorder had its onset in 2003. It was initially assessed as bursitis and treated with steroid injections, which did not provide any relief. An MRI examination revealed a torn tendon. The Veteran reported further that she experienced flare-ups with repeated motion, such as raking in the yard. She took Ultracet for pain and obtained manipulative treatment from an osteopath once a month. Id., P. 2. Physical examination revealed no evidence of swelling, effusion, tenderness, or laxity. Neither was there evidence of ankylosis. ROM was 0 to 180 degrees on flexion and abduction, and 0 to 90 degrees on external and internal rotation, all without pain. Muscle and motor strength, reflexes, and sensation were all normal. Id., P. 10, 14. The examiner diagnosed right shoulder SLAP with intermittent flare-ups, asymptomatic. Id., P. 17. The objective findings on clinical examination show that the Veteran’s right shoulder manifested with pain-free normal ROM above shoulder level, which is 90 degrees. See 38 C.F.R. § 4.71a, Plate II; DC 5201. Further, the examiner noted that there was no loss of ROM on repetitive-use testing. See 38 C.F.R. §§ 4.40, 4.45. The Board notes that the examination report does not indicate that passive ROM was tested nor did the examiner assessed the impact of the Veteran’s reported flare-ups. See Sharp v. Shulkin, 29 Vet. App. 26 (2017); Correia v. McDonald, 28 Vet. App. 158 (2016). Nonetheless, the Veteran did not, and has not, asserted that the examination was inadequate in any way. Hence, the Board finds no prejudice. See Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). Thus, the Board finds that as of the August 2011 examination, the Veteran’s right shoulder most nearly approximated the assigned non-compensable rating. 38 C.F.R. §§ 4.1, 4.10, 4.31, 4.40, 4.45, 4.59, 4.71a, DC 5201. At her hearing, the Veteran testified that she underwent an 8-week regimen of physical therapy for the right shoulder. 11/21/2017 Hearing Testimony, P. 14-19. Her VA outpatient records note that on her presentation on June 16, 2017, right shoulder muscle strength was 3/5 on flexion, 4+/5 on abduction; ROM on flexion was 0 to 138 degrees, and 0-150 degrees on abduction; and, 1/10 pain was noted. See 07/12/2017 CAPRI, P. 18-19. The entry does not indicate whether the Veteran’s pain was throughout the entire range of ROM. The Board resolves that ambiguity in the Veteran’s favor. Hence, the criteria for the minimum compensable rating, 20 percent, were met. 38 C.F.R. §§ 4.59, 4.71a, DC 5201. A higher rating is effective on the earliest date on which it is factually ascertainable that entitlement arose. See 38 C.F.R. § 3.400. The Board notes a June 2015 mental health entry wherein the Veteran reported that one of her issues was right shoulder pain. See 04/29/2016 CAPRI, P. 130. As noted earlier, the Veteran is competent to report the symptoms of her disability. See 38 C.F.R. § 3.159(a)(2). Hence, the Board allows the 20 percent rating as of June 16, 2015, the date of the entry wherein her complaint of right shoulder pain was noted. 38 C.F.R. §§ 3.102, 3.400. 2. Entitlement to an initial compensable rating for IBS Rating Criteria The AOJ evaluated this disability under 38 C.F.R. § 4.114, DC 7319. Under these criteria, a noncompensable evaluation is warranted for mild IBS, with disturbances of bowel function with occasional episodes of abdominal distress; a 10 percent evaluation is warranted for moderate IBS, with frequent episodes of bowel disturbance with abdominal distress; and, a 30 percent evaluation is warranted for severe IBS, with diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress. With regard to coexisting abdominal disabilities, a VA regulation recognizes that there are diseases of the digestive system, particularly within the abdomen, which, while differing in the site of pathology, produce a common disability picture characterized in the main by varying degrees of abdominal distress or pain, anemia and disturbances in nutrition. 38 C.F.R. § 4.113. Consequently, certain coexisting diseases in this area do not lend themselves to distinct and separate disability evaluations without violating the fundamental principle relating to pyramiding as outlined in 38 C.F.R. § 4.14. See id. Rather, a single evaluation will be assigned under the Diagnostic Code which reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. See 38 C.F.R. § 4.114. The Board also notes that the schedule of ratings for the digestive system, 38 C.F.R. § 4.114 expressly prohibits, in pertinent part, the combination of ratings under Diagnostic Codes 7301 to 7329, inclusive, 7331, 7342 and 7345 to 7348 which include the schedular criteria for IBS (Diagnostic Code 7319). Discussion The VA examination report (08/11/2011 VA Examination, 2nd Entry) reflects that the Veteran’s examination was conducted prior to her medical discharge from active service. The Veteran reported that she had experienced IBS symptoms since 2000, when she started having constipation followed by diarrhea, bloating, and abdominal pain. She denied having ever undergone an endoscopy as well as a history of blood in her stool but she had observed intermittent mucus. The Veteran reported daily IBS symptoms with variable nausea and vomiting about once a month or once every two months. She denied any weight loss. She took Bentyl in the evenings when her symptoms were bad enough, and Zofran for the nausea and vomiting. She also stopped eating when symptomatic. Her symptoms could last up to three days. Abdominal examination revealed normal bowel sounds with no evidence of masses, hernia, tenderness or guarding. Based on the Veteran’s reported lay history, the review of her service treatment records (STRs), and the examination, the examiner diagnosed IBS with daily symptoms of alternate constipation and diarrhea, with partial relief from medication. Id., P. 4, 7, 17. The AOJ assigned an initial 0 percent (noncompensable) rating for the IBS. See 10/05/2012 Rating Decision-Narrative. The Veteran’s primary assertion in her NOD was that the AOJ had reduced her rating from 10 percent to 0 percent. See 11/13/2012 VA 21-4138. The Veteran’s assertion was based on a November 2011 rating decision that the AOJ issued after the August 2011 VA examination. This rating decision specifically informed the Veteran, however, that the ratings therein were proposed. See 11/18/2011 Rating Decision. (Emphasis added). The November 2011 rating decision reflected the rating criteria with no discussion of the evidence, whereas the October 2012 rating decision reflects that the AOJ applied the findings of the August 2011 VA examination. Thus, there has been no reduction in this case. VA outpatient records note an active prescription for medication for the stomach. See 03/30/2016 Medical Treatment-Government Facility, P. 3. A higher rating may not be denied due to the relief provided by medication when those effects are not specifically contemplated by the rating criteria. Jones v. Shinseki, 26 Vet. App. 56, 63 (2012). DC 7319 does not expressly consider the effects of medication. See 38 C.F.R. § 4.114. Hence, the Board finds that the preponderance of the entire record tips towards the minimum compensable rating of 10 percent, Id. The Board finds that a higher rating has not been met or approximated, as the examination report noted that the Veteran reported significantly increased symptoms about once a month to every two months. The Board finds that such symptoms do not more nearly approximate severe IBS, with diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress. In fact, at her hearing, in response to the undersigned’s question if there was any additional information she wanted to share, the Veteran responded that she would like to receive more attention from VA for her IBS, but that her symptoms were so infrequent, and that there also was the fact that she lived a long distance from the VA treatment facility. See 11/21/2017 Hearing Transcript, P. 35-36. She did, however, also testify to recently increased symptoms, to include during her drive to the hearing. She also noted unusual weight gain since June 2016. Hence, the Board finds it appropriate to close the current rating period as of June 1, 2016 and finds that the evidence more nearly approximates the allowed 10 percent rating for the period prior to that date. 38 C.F.R. §§ 4.1, 4.10, 4.114, DC 7319. This disability is discussed further in the remand section later in this decision. Entitlement to an initial compensable rating for chronic interstitial cystitis Rating Criteria The rating criteria require that all forms of cystitis be evaluated as voiding dysfunction. See 38 C.F.R. § 4.115b, DC 7512. Discussion The rating criteria are based solely on urine leakage, frequency, or obstruction. The problem, however, is that the Veteran’s disorder does not involve any of those symptoms. So naturally, the AOJ assigned a noncompensable rating. This does not do the Veteran justice. The examination report reflects that the disorder had onset in 2008. The Veteran had recurrent UTIs and proteinuria. A cystography showed an autoimmune process that caused cystitis. The Veteran reported further that she opted not to undergo immunotherapy because of the potential side effects. She took Atarax for control of her symptoms, and that she required antibiotic treatment for UTIs three times a year. 08/11/2011 VA Examination, 2nd Entry, P. 3. As the examination report noted, the Veteran took medication to control her symptoms, to include intermittent antibiotic treatment for UTIs. At the hearing, she testified that as long as she could obtain her medication, the disorder was controlled; but without it, she contracted constant UTIs. Further, as she is able to obtain her medication through VA, she has not had a UTI over the prior five years. See Hearing Transcript, P. 30-36. Any layperson is competent to report the symptoms she has experienced from a disorder. See 38 C.F.R. § 3.159(a)(2). Further, the Veteran as also received medical training, as her duties entailed working in a clinic. Given the specific facts of this case, the Board finds that the Veteran’s chronic interstitial cystitis more nearly approximates long-term drug therapy for UTI instead of voiding dysfunction, and allows a 10 percent rating. 38 C.F.R. § 4.1, 4.115a, 4.115b, DC 7512. It is noted that voiding frequency problems were denied at the hearing and have not been demonstrated elsewhere of record such as to enable a rating in excess of 10 percent. 3. Entitlement to an initial compensable rating for endometriosis Rating Criteria Pursuant to 38 C.F.R. §4.116, DC 7629, a 10 percent rating is warranted for endometriosis that manifests as pelvic pain or heavy or irregular bleeding requiring continuous treatment for control; a 30 percent rating is warranted for pelvic pain or heavy or irregular bleeding not controlled by treatment; and, a 50 rating is warranted for lesions involving bowel or bladder confirmed by laparoscopy, pelvic pain or heavy or irregular bleeding not controlled by treatment, and bowel or bladder symptoms. Discussion The examination report in August 2011 reflects that an in-service laparoscopic procedure diagnosed endometriosis, and that the Veteran was placed on the contraceptive Depo for eight years as treatment until she broke her ankle. After treatment for the broken ankle she was placed on a different contraceptive. At the time of the examination she had been placed back on Depo, and the disorder was asymptomatic. See 08/11/2011 VA Examination, 2nd Entry, P. 3. The AOJ assigned the noncompensable rating solely on the basis that the disorder is asymptomatic, apparently without consideration of why it is asymptomatic. The examination report noted the fact that the Veteran was prescribed contraceptives to control her symptoms. She testified that she took Depo shots for her bleeding, and that without the shots she experienced severe pelvic pain. See Hearing Testimony, P. 23-30. VA outpatient records dated in April 2017 note the fact that she takes injections for bleeding due to endometriosis. See 09/27/2017 CAPRI, P. 193. DC 7629 does not specifically provide for the affect of medication, but it does provide for a 10 percent rating where pelvic pain or heavy or irregular bleeding require continuous treatment. The Board finds that in all probability the Veteran’s continued need for injections is what prevents the need for continuous treatment. Since the rating criteria do not specifically include the effect of medication, the Board finds that a 10 percent rating has been more nearly approximated. 38 C.F.R. §§ 4.1, 4.10, 4.116, DC 7629; see also Jones, 26 Vet. App. at 63. 4. Entitlement to an initial compensable rating for migraine headaches Rating Criteria The applicable rating criteria provide for a 10 percent rating for migraine headaches with characteristic prostrating attacks occurring on an average once in 2 months over a period of several months; a 30 percent rating is warranted for migraine headaches with characteristic prostrating attacks occurring on an average once a month over a period of several months; and, the maximum rating of 50 percent is warranted for migraine headaches with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 38 C.F.R. § 4.124a, DC 8100. The rating criteria do not define “prostrating,” nor has the U.S. Court of Appeals for Veterans Claims. By way of reference, a definition is found in Dorland’s Illustrated Medical Dictionary 1554 (31st Ed. 2007), in which “prostration” is defined as “extreme exhaustion or powerlessness.” Discussion The Veteran reported having migraine headaches since 1996. Her headaches are accompanied by aura that included visual and sensory. Apparent triggers include certain foods, change in sleeping patterns, caffeine intake, and stress level. Her treatment included Imitrex injections for visual aura; Fioricet for pre-headaches tingling of the fingers; and, Topamax daily as a prophylaxis. At the time of the examination, she had experienced one episode over the prior 12 months in May 2011. 08/11/2011 VA Examination, 2nd Entry, P. 2. The September 2016 examination report/DBQ Questionnaire (09/27/2016 C&P Examination, 1st Entry) reflects a diagnosis of migraines/variants. The Veteran reported that she took medication daily (Topamax), and monthly (Imitrex). With that regimen she had headaches usually about once a month. The pain was pulsating or throbbing on both sides of her head, and they lasted more than 2 days. She had to be in a dark room when she was experiencing a headache. In the block where the examiner notes non-headaches symptoms, the examiner checked all. Id., P. 2. The examiner also assessed characteristic prostrating attacks that averaged one in 2 months over the prior several months. Id., P. 2. The Veteran’s outpatient records reflect her complaint of headaches of varying frequency and severity, to include vomiting. See 07/1/2017 CAPRI, P. 5, 281, 515, 594. At the hearing, the Veteran testified that her headaches lasted about 2 days and were accompanied by vomiting and light sensitivity. She had to go to the emergency room in 2014 when she ran out of her medications. The Veteran testified further that when she did not, or could not take her Topamax, she had headaches between weekly to bi-weekly, they lasted for up to 4 days, during which she was totally incapacitated where she had to be in total darkness and free from noise. She also testified that an increase in the dosages of her medications in October 2017 had helped, and that her migraines dehydrated her which in turn aggravated her IBS. Hearing testimony, P. 6-14. As is the case with the Veteran’s endometriosis, the migraine headaches rating criteria do no account for the impact of medication. Hence, the Board finds that the evidence of record, to include the Veteran’s sworn testimony, is at least in equipoise as to whether the migraine headaches would, without the benefit of prescribed medication, manifest with characteristic prostrating attacks that occur on average once a month over the last several months. Hence, the Board allows a 30 percent rating for the rating period up to November 21, 2017. 38 C.F.R. § 4.1, 4.3, 4.10, 4.124a, DC 8100; see also Jones, 26 Vet. App. at 63. From that date forward, the hearing testimony indicates “very frequent” headaches productive of economic inadapatability (total incapacitation for 4 days per episode, by her account, with episodes weekly or biweekly) such as to warrant a 50 percent evaluation during the period in question. The Board notes that there is no indication in the claims file that the AOJ issued a Supplemental Statement of the Case (SSOC) after receipt of the September 2016 examination report. See 38 C.F.R. § 19.31. The Board finds that any error is cured by the increase allowed above, and that a remand for issuance of an SSOC is not required. 5. Entitlement to an initial compensable rating for CTS Discussion The examination report (08/11/2011 VA Examination, 2nd Entry) reflects that the Veteran used a computer a lot in 1999 when she started have tingling in the dorsal aspect of the hand and right thumb. A nerve conduction study was interpreted as having shown CTS, and she was treated with a splint along with instructions on proper keyboard use. The Veteran reported that she used wrist supports when she typed, and that she was currently asymptomatic. Id., P. 2. At the hearing, the Veteran testified that her right hand bothered her only when she used a computer, and that her thumb got numb on prolonged use, which she estimated to be 25 minutes or more. She testified further that when the CTS is symptomatic she would not attempt to lift a cup of coffee, but she still could button a shirt. Hearing Testimony, P. 20-23. The AOJ rated the CTS analogously to incomplete paralysis of the median nerve. See 38 C.F.R. §§ 4.20, 4.124a, DC 8599-8515. The Board does not set forth the rating criteria since the evidence of record shows that, up to the date of the hearing, the disorder manifested as asymptomatic, and the Veteran had not taken any medication for it. The Veteran testified to recently increased symptoms, Hence, the Board finds it appropriate to close the current rating period as of the day prior to the hearing and find that the evidence more nearly approximates the assigned noncompensable rating for that prior period. 38 C.F.R. §§ 4.1, 4.10, 4.31, 4.124a, DC 8599-8515. This disability is discussed further in the remand section later in this decision. As noted earlier in this decision, the Veteran is entitled to a staged rating where indicated by the evidence, and the Board has allowed one where indicated. Otherwise, the Board finds that her disabilities have manifested at the rate allowed by the Board for the entire rating period on appeal. The Board also finds that the evidence does not show that the occupational impairment of either disability, or the cumulative impact of all, has precluded the Veteran from obtaining and maintaining substantially gainful employment. See 38 C.F.R. §§ 3.340, 3.341, 4.16. She testified that she was a full-time student. REASONS FOR REMAND 1. Entitlement to an initial rating higher than 10 percent for IBS for the period November 21, 2017 forward is remanded. The Veteran’s hearing testimony indicated that her disability has worsened in severity. Further, the Veteran is also service connected for GERD. Hence, an examiner needs to delineate the symptoms of each disability and determine which one is dominant. 2. Entitlement to an initial compensable rating for right CTS is remanded. The Veteran also testified to increased symptomology for her CTS. Hence, she is entitled to current examinations. The matters are REMANDED for the following action: 1. Arrange an examination by an appropriate examiner to determine the current severity of the Veteran’s IBS. The examiner should identify the symptoms attributable to the Veteran’s IBS, and those attributable to her GERD and determine which one is predominant. (Continued on the next page)   2. Arrange an examination by an appropriate examiner to determine the current severity of the Veteran’s right CTS. All indicated diagnostic tests should be conducted. Eric S. Leboff Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD W.T. Snyder