Citation Nr: 0006208 Decision Date: 03/08/00 Archive Date: 03/17/00 DOCKET NO. 98-10 707 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Los Angeles, California THE ISSUES 1. Entitlement to service connection for a chronic skin disorder, claimed as neurodermatitis and/or "skin tags." 2. Entitlement to service connection for epistaxis (nosebleeds). 3. Entitlement to an evaluation in excess of 10 percent for hypertension. 4. Entitlement to a compensable evaluation for bilateral defective hearing. 5. Entitlement to a compensable evaluation for the residuals of dislocation of the left shoulder. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Stephen F. Sylvester, Counsel INTRODUCTION The veteran served on active duty from June 1965 to February 1972, with an additional period of unverified service from July 1961 to June 1964. For reasons which will become apparent, the issues of entitlement to increased evaluations for service-connected hypertension and defective hearing, and the residuals of dislocation of the left shoulder, will be the subjects of the REMAND portion of this decision. FINDINGS OF FACT 1. The claim for service connection for a chronic skin disorder, claimed as neurodermatitis and/or "skin tags," is not supported by cognizable evidence showing that this disability was present in service, or is the result of any incident or incidents of the veteran's active service, including exposure to Agent Orange in the Republic of Vietnam. 2. The claim for service connection for epistaxis (nosebleeds) is not supported by cognizable evidence showing that this disability was present in service, or is the result of any incident or incidents of the veteran's active service, including exposure to Agent Orange in the Republic of Vietnam. CONCLUSIONS OF LAW 1. The claim for service connection for a chronic skin disorder, claimed as neurodermatitis and/or "skin tags" is not well grounded. 38 U.S.C.A. § 5107 (West 1991 & Supp. 1998). 2. The claim for service connection for epistaxis (nosebleeds) is not well grounded. 38 U.S.C.A. § 5107 (West 1991 & Supp. 1998). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Factual Background Service medical records disclose that, in November 1961, the veteran was seen for rubella which was in its final stages. At the time of evaluation, there was noted a rash which had been fading for three days. When questioned, the veteran stated that he felt "OK." Treatment was with medication. In October 1962, the veteran was seen for a rash on the dorsal aspect of both hands. Physical examination revealed the presence of raised noninflamed lesions, with occasional mild pruritus. Additionally noted was the presence of "athlete's foot." The clinical impression was dyshidrosis. In early November 1962, and once again in late May 1963, the veteran was seen for problems involving a sty on his eyes. Treatment was with medication. In mid-February 1964, there was noted a half-dollar size area of partial alopecia on the veteran's right occipital scalp. Dermatologic evaluation revealed an old area of alopecia areata in the right parietal region. The hair in that area was described as "growing back well." Additionally noted was an area of LSC on the veteran's right lower leg near his right ankle. Treatment was with medication. On service separation examination in January 1972, the veteran's skin and nose were entirely within normal limits, and no pertinent diagnoses were noted. At the time of various Department of Veterans Affairs (VA) medical examinations in April 1976, the veteran's nose and skin were within normal limits. A private outpatient treatment record dated in June 1986 reveals that the veteran was seen at that time for verruca vulgaris which had been "bothering him." Treatment was by cauterization. A private outpatient treatment record dated in August 1987 is to the effect that the veteran was seen at that time for a rash on both hands. At the time of evaluation, the veteran complained of itching which had been present for approximately one month. He further noted that he had experienced the "same thing when he was a teenager." Physical examination revealed the presence of whitish scaly discoloration in the area of the veteran's left wrist, in addition to dryness. The pertinent diagnosis was dermatitis, fungal versus ectopic; psoriasis. During the course of private outpatient treatment in late November 1989, the veteran complained of itching and "flakes" on the bottom of his feet. The pertinent diagnosis was fungal itching. A private outpatient treatment record dated in December 1993 reveals that the veteran was seen at that time for a rash on his hands. Treatment was with medication. In June 1994, the veteran was seen at a private medical clinic with a complaint of a rash in his inguinal area. At the time of evaluation, it was noted that the veteran had "relapsed" after several months. The clinical assessment was fungal dermatitis. VA and private outpatient treatment records dated in September 1996 reveal that the veteran was seen at that time for epistaxis/nosebleeds. In early September 1996, the veteran was heard to complain of epistaxis from his right nostril which had been present for two days. Reportedly, the veteran had previously been seen in the emergency room, at which time his blood pressure was 230/130. At that time, his bleeding stopped with digital pressure and control of his blood pressure. However, the bleeding had restarted the previous night, with the result that the veteran returned to the emergency room. Despite various attempts, the veteran received no relief with digital pressure. His nose was therefore packed with gauze. The veteran gave no prior history of nosebleeds or easy bruising, or of hemophilia. It was further noted that the veteran had been taking Anacin for occasional pain. On physical examination, there was noted the presence of packing in the right naris, which was removed. The veteran's septum on the right showed no evidence of any active bleeding. The clinical assessment was epistaxis of the right nostril, relieved by digital pressure. The following day, the veteran was once again seen for outpatient treatment of a "nosebleed." At the time of evaluation, it was noted that the veteran had been sent home, but that he returned four hours later with a nosebleed. Physical examination was positive for evidence of epistaxis in the veteran's right nostril. Additionally noted was the presence of a laceration of the midnasal septum. Following treatment with silver nitrate and surgical gauze, the veteran's epistaxis resolved. The clinical assessment was epistaxis with septal laceration. Approximately four days later, the veteran was once again seen for problems associated with a nosebleed. At the time of evaluation, it was noted that the veteran had experienced recurrent epistaxis since September 4th, and that, despite, nasal packing and silver nitrate coagulation, he continued to have one episode of epistaxis per day. Physical examination revealed blood pressure of 179/105. The clinical assessment was right anterior laceration. Approximately three days later, the veteran was seen for follow up of his prior epistaxis. Physical examination revealed the presence of slight mucosal irritation, but no erosion or bleeding from the veteran's septum. The clinical assessment was status post epistaxis, resolved; hypertension controlled. Approximately one week later, the veteran was seen for follow up of his nasal bleeding. At the time of evaluation, the veteran's epistaxis was described as resolved, and his hypertension as controlled. His septum was intact, and there was no evidence of any bleeding or mass. The clinical assessment was resolved epistaxis. In January 1997, a VA medical examination was accomplished. At the time of examination, the veteran stated that, in late 1996, he had experienced several nosebleeds, at which time his blood clotting was found to be normal. Reportedly, on one of the veteran's visits to the emergency room, his blood pressure was 230/130. The veteran's current medication consisted of Nifedipine, Nadolol, and Clonidine. The veteran stated that his blood pressure varied on this medication, and that he had "no direct complaints" relative to his blood pressure "except perhaps the nosebleeds." On physical examination, serial blood pressures over a period of 45 minutes were 166/92 in the left arm sitting, 174/98 in the left arm standing, and 156/90 in the right arm standing. Somewhat later, the veteran's blood pressure was 160/92 in the left arm in the sitting position, and 166/96 in the left arm in the standing position. Later, the veteran's blood pressure was 160/102 in the sitting position, and 158/100 in the standing position. On physical examination of his skin, the veteran stated that, "on and off" since 1973, he had experienced "pink itching areas" around the base of some of the fingers of his hands. Additionally noted was that, for approximately one year, he had noticed asymptomatic skin tags in his "axillae." Physical examination showed a number of pink, flat hyperkeratotic areas measuring 1 by 1 centimeter to 0.5 by 1 centimeter over the knuckles of the veteran's right hand joints 2, 3, and 5. The axillae showed many classic skin tags, and there were lesions about the knuckles which were oval to irregular in contour, and which appeared to have been abraded. The pertinent diagnoses were hypertension with elevated readings as discussed above and as shown on physical examination; and skin lesions consistent with neurodermatitis and skin tags. Additionally noted was that the level of the veteran's blood pressure readings was dependent on his compliance with his medication regimen, as well as the regimen itself. According to the examining physician, Nifedipine in the doses prescribed for the veteran was not "an approved use for formulation of the drug for hypertension." During the course of VA outpatient treatment in late March 1997, the veteran gave a history of epistaxis for seven months. No pertinent diagnosis was noted. Analysis As to the issues of service connection for a chronic skin disorder and epistaxis, the threshold question which must be resolved is whether the veteran's claims are well grounded. See 38 U.S.C.A. § 5107(a) (West 1991 & Supp. 1998); Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). A well-grounded claim is a plausible claim, meaning a claim which appears to be meritorious. See Murphy, 1 Vet. App. 81. A mere allegation that a disability is service connected is not sufficient; the veteran must submit evidence in support of his claims which would "justify a belief by a fair and impartial individual that the claims are plausible." 38 U.S.C.A. § 5107(a) (West 1991 & Supp. 1998); Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992). In order for a claim to be well grounded, there must be competent evidence of current disability (medical diagnosis), of incurrence or aggravation of a disease or injury in service (lay or medical evidence), and of a nexus between the inservice injury or disease and the current disability (medical evidence). See Caluza v. Brown, 7 Vet. App. 498 (1995); see also Epps v. Gober, 126 F.3d 1464 (Fed. Cir. 1997); Heuer v. Brown, 7 Vet. App. 379 (1995); Grottveit v. Brown, 5 Vet. App. 91 (1993). The second and third elements of this equation may also be satisfied under 38 C.F.R. § 3.303(b) (1999) by (a) evidence that a condition was "noted" during service or during an applicable presumptive period; (b) evidence showing post service continuity of symptomatology; and (c) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post service symptomatology. See 38 C.F.R. § 3.303(b) (1999); Savage v. Gober, 10 Vet. App. 488 (1997). Alternatively, service connection may be established under 38 C.F.R. § 3.303(b) by evidence of (i) the existence of a chronic disease in service or during an applicable presumptive period and (ii) present manifestations of the same chronic disease. Ibid. For the purpose of determining whether a claim is well grounded, the credibility of the evidence in support of the claim is presumed. See Robinette v. Brown, 8 Vet. App. 69 (1995). Service connection may be granted for disability resulting from disease or injury incurred or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131 (West 1991 & Supp. 1998). Moreover, where a veteran was exposed to an herbicide agent during active military, naval, or air service, the following diseases shall be service connected, even though there is no record of such disease during service: chloracne or other acneiform disease consistent with chloracne, Hodgkin's disease, multiple myeloma, non- Hodgkin's lymphoma, porphyria cutanea tarda, prostate cancer, acute and subacute peripheral neuropathy, respiratory cancers (that is, cancers of the lung, bronchus, larynx, or trachea) or soft tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). 38 C.F.R. § 3.309(a) (1999). These diseases shall become manifest to a degree of 10 percent or more at any time after service, except that chloracne, other acne disease consistent with chloracne, porphyria cutanea tarda, and acute and subacute peripheral neuropathy shall become manifest to a degree of 10 percent of more within a year, and respiratory cancers within 30 years, after the last date on which the veteran was exposed to an herbicide agent during active military, naval, or air service. 38 U.S.C.A. § 1116 (West 1991 & Supp. 1998); 38 C.F.R. § 3.307(a)(6)(ii) (1999). Finally, service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. Presumptive periods are not intended to limit service connection to diseases so diagnosed when the evidence warrants direct service connection. 38 C.F.R. § 3.303(d) (1999). In the present case, service medical records do not document the existence of a chronic skin disorder or epistaxis (that is, nosebleeds). While on a number of occasions in service, the veteran received treatment for various skin-related problems, these episodes were acute and transitory in nature, and resolved without residual disability. At no time during service did the veteran complain of, or receive treatment for, "nosebleeds." Moreover, as of the time of the veteran's service separation in January 1972, his skin and nose were entirely within normal limits, and no pertinent diagnoses were noted. The earliest clinical indication of the presence of a potentially chronic skin disorder is revealed by a private outpatient treatment record dated in June 1986, more than 14 years following the veteran's discharge from service, at which time he received treatment for verruca vulgaris. Epistaxis was first shown no earlier than 1996, fully 24 years following the veteran's service separation. The veteran argues that his recurrent "nosebleeds" are, in fact, the result of his service-connected hypertension. In that regard, service connection may be granted for disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a) (1999). However, in the case at hand, there exist no competent medical evidence whatsoever that the veteran's post service problems with "nosebleeds" were, in fact, the direct result of his service-connected hypertension. Indeed, as of September 1996, the veteran's problems with epistaxis were described as "resolved." Moreover, on recent VA examination in January 1997, there was noted only a history of nosebleeds in late 1996, with no demonstrated clinical evidence of current pathology. The Board concedes that, since the time of the veteran's discharge from service, he has received treatment for various skin-related problems, including the aforementioned verruca vulgaris, as well as fungal dermatitis and neurodermatitis with skin tags. However, on no occasion has such pathology been in any way attributed to the veteran's active military service, or to exposure to herbicides (that is, Agent Orange) in Vietnam. Moreover, none of these pathologies represent a disease or disability for which service connection might presumptively be granted on the basis of herbicide (that is, Agent Orange) exposure in the Republic of Vietnam. At no time has the veteran been shown to suffer from a skin disorder such as chloracne, or any other acneiform disease consistent with chloracne, either in service, or within the first year following service discharge. 38 C.F.R. § 3.309 (1999). Indeed, as noted above, the first clinical indication of the presence of any of the disabilities in question was in 1986, more than 14 years following the veteran's discharge from service. Absent objective evidence of some disease or disability for which service connection might be granted on a presumptive basis, the veteran is not entitled to the inservice presumption of exposure to an herbicide agent. See McCartt v. West, 12 Vet. App. 164 (1999). The veteran argues that his exposure to Agent Orange was, in fact, the precipitating factor in the development of his post service skin pathology. However, the veteran's opinion that his current skin problems are in some way "linked" to Agent Orange exposure in service does not constitute competent medical evidence, inasmuch as there is no evidence that he was trained in the field of medicine. Espiritu v. Derwinski, 2 Vet. App. 492 (1992); Grottveit v. Brown, 5 Vet. App. 91 (1993). Absent a showing that the veteran's exposure to herbicides during service actually caused his post service skin pathology, or that his claimed epistaxis is in some way related to service or to service-connected hypertension, the veteran's claims are not well grounded, and must therefore be denied. ORDER Service connection for a chronic skin disorder, claimed as neurodermatitis and/or "skin tags," is denied. Service connection for epistaxis (nosebleeds) is denied. REMAND In addition to the above, the veteran in this case seeks an increased evaluation for service-connected hypertension, as well as bilateral defective hearing, and the residuals of dislocation of his left shoulder. In that regard, at the time of a hearing before a member of the Board in November 1999, the veteran's accredited representative stated that the veteran had most recently undergone a VA examination for compensation purposes in 1997, almost three years previously. In light of that fact, it was requested that the veteran be afforded "updated" VA examinations prior to a final adjudication of his current claims for increased evaluations. The Board notes that, pursuant to various decisions of the United States Court of Appeals for Veterans Claims (Court), in cases where an increased evaluation for service-connected disabilities is at issue, a contemporaneous examination is required prior to final adjudication of the veteran's claims. See Olsen v. Principi, 3 Vet. App. 480 (1992), citing Proscelle v. Derwinski, 2 Vet. App. 629, 632 (1992). Accordingly, in light of the aforementioned, the case is REMANDED to the Regional Office (RO) for the following actions: 1. Any pertinent VA or other inpatient or outpatient treatment records, subsequent to May 1997, the date of the most recent treatment of record, should be obtained and incorporated in the claims folder. The veteran should be requested to sign the necessary authorization for release of any private medical records to the VA. 2. The veteran should then be afforded additional examinations by appropriate specialists in order to more accurately determine the current severity of his service-connected hypertension, hearing loss, and left shoulder pathology. All pertinent symptomatology and findings should be reported in detail. The claims file and a separate copy of this REMAND must be made available to and reviewed by the examiners prior to conduction and completion of their examinations. 3. Thereafter, the RO should review the claims file to ensure that all of the requested development has been completed. In particular, the RO should review the requested examination reports to ensure that they are responsive to and in complete compliance with the directives of this REMAND, and if they are not, the RO should take corrective action. 4. After undertaking any development deemed appropriate in addition to that requested above, the RO should readjudicate the issues of increased evaluations for the veteran's service-connected hypertension, bilateral defective hearing, and residuals of dislocation of the left shoulder. Should the benefits requested on appeal not be granted to the veteran's satisfaction, the RO should issue a supplemental statement of the case. A reasonable period of time for response should be afforded. Thereafter, the case should be returned to the Board for final appellate review, if otherwise in order. By this REMAND, the Board intimates no opinion as to any final outcome warranted. No action is required of the veteran until he is so notified by the RO. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded to the regional office. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment by the RO. 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 The Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 302, 108 Stat. 4645, 4658 (1994), 38 U.S.C.A. § 5101 (West Supp. 1999) (Historical and Statutory Notes). In addition, VBA's Adjudication Procedure Manual, M21-1, Part IV, directs the ROs to provide expeditious handling of all cases that have been remanded by the Board and the Court. See M21-1, Part IV, paras. 8.44- 8.45 and 38.02-38.03. John E. Ormond, Jr. Member, Board of Veterans' Appeals Error! Not a valid link.