BVA9503976 DOCKET NO. 92-08 580 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for a psychiatric disorder and a right knee disability. 2. Entitlement to an increased evaluation for rhinitis and sinusitis, currently rated as 10 percent disabling. REPRESENTATION Appellant represented by: Alabama Department of Veterans Affairs ATTORNEY FOR THE BOARD Richard V. Chamberlain, Counsel INTRODUCTION The veteran served on active duty from February 1986 to April 1990. This appeal arises from a March 1991 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama, that denied service connection for a psychiatric disorder and a right wrist disability; and granted service connection for rhinitis and sinusitis, and assigned this disorder a 10 percent rating (the veteran disagreed with the rating assigned for this disorder). The Board of Veterans' Appeals (Board) remanded the case to the RO in March 1993 for additional development. The case was returned to the Board in January 1995. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends that the stress of service caused his current psychiatric disability. He asserts that he was treated for a psychiatric problem in 1987 while in service and he requests service connection for his current psychiatric disorder. He maintains that he sustained an injury to his right wrist when he fell on ice in February 1989 and sustained a left knee disorder. He also maintains that the use of a cane for his service-connected left knee disorder aggravates his right wrist, and he requests service connection for a right wrist disorder. Additionally, he maintains that his service-connected sinusitis and rhinitis disorder is more severe than currently rated, and requests a higher rating for this disorder. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991), has reviewed and considered all of the evidence and material of record in the veteran's claims file and vocational rehabilitation (38 U.S.C.A., Chapter 31) file. Based on its review of the relevant evidence, and for the following reasons and bases, it is the decision of the Board that the preponderance of the evidence is against the claims for service connection for a psychiatric disorder and a right wrist disabililty, and the claim for an increased evaluation for rhinitis and sinusitis. FINDINGS OF FACT 1. A chronic acquired psychiatric disorder was not present during service or until July 1991, and a current psychiatric disorder was not caused by an incident of service. 2. A chronic right wrist disability was not present during service, and a chronic right wrist disability found after service was not caused by an incident of service. 3. The veteran's rhinitis and sinusitis are manifested primarily by occasional secretion, erythema, swelling, discharge, and tenderness; crusting, ozena and atrophic changes due to rhinitis that produce moderate impairment are not found; frequent incapacitating recurrences, severe and frequent headaches, and purulent discharge or crusting reflecting purulence due to sinusitis that produce severe impairment are not found. CONCLUSIONS OF LAW 1. A chronic acquired psychiatric disorder was not incurred in or aggravated in service, nor may schizo-affective bipolar disorder be presumed to have been incurred in active service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 1137 (West 1991); 38 C.F.R. §§ 3.303, 3.307, 3.309 (1993). 2. A chronic right wrist disorder was not incurred in or aggravated by active service. 38 U.S.C.A. § 1131 (West 1991); 38 C.F.R. § 3.303 (1993). 3. The criteria for a rating in excess of 10 percent for rhinitis and sinusitis are not met. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. §§ 3.321, 4.7, Part 4, Codes 6501, 6510 (1993). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Factual Background The veteran served on active duty from February 1986 to April 1990. The service medical records show that the veteran was seen at a base clinic in Fallon, Nevada, in August 1987 for possible drug dependence. On observation, he was not nervous appearing and no abnormalities were noted. The assessment was no evidence of a psychological dependence, physical dependence or long-term use of illicit drugs. The service medical records show that the veteran was seen in October 1988 for a painful fourth finger of the right hand. The assessment was fourth digit sprain. It was noted that he was taking medication for this condition and he was advised to continue and to return to the clinic. Later in October 1988, he was seen for complaints of pain of the fourth (ring) finger of the right hand at the middle phalanx for eight days. He stated that it hurt his finger when he curled his hand and held it open. On observation, there was slight pain to palpation of the middle phalanx. The ligaments appeared intact and there was no swelling. There no was ecchymosis. The assessment was soft tissue injury. The service medical records show that the veteran received emergency care and treatment in February 1989. He complained of pain in the left knee, and stated that he had slipped and fell on a patch of ice. He was treated for a left knee disorder. A report of treatment in March 1989, notes that the veteran had slipped on some ice sustaining a hyperextension possibly twisting injury when he fell backwards onto his buttocks. The reports concerning his treatment in February and March 1989 do not show any complaints or findings pertinent to any right wrist condition. The veteran underwent medical board examination in August 1989. Physical examination was normal except for left knee disorders. He underwent another medical board examination in December 1989 and again only left knee disorders were found. In April 1990, he was discharged from service because of medical disability, left knee disorders. The veteran submitted his initial claim for VA compensation in April 1990. In it, he reported no psychiatric problems or right wrist disorder. The veteran underwent VA examination in June 1990. He gave a history of a fracture of the right ring finger in service. He stated that he complained about his right ring finger in service, but that it was never X-rayed. He believed that it was fractured and stated that he had a throbbing pain in the finger that was fairly constant, and aggravated by trying to grasp objects or throwing a ball. He complained of bad and almost constant nasal discharge which he treated with medication and a steroid spray. He also complained of frontal headaches. Examination of his nose, sinuses, mouth, and throat showed no abnormalities. The right ring finger looked normal but there may have been some limitation of flexion. X-rays of the sinuses were clear, and there was no evidence of sinusitis. X-ray of the right hand showed no abnormalities. The diagnoses included no objective abnormality of the right ring finger with normal X-rays; and no X-ray evidence of sinusitis and a normal physical examination of the nose. It was noted that the veteran had complaints of nasal discharge that was not explained and that allergic rhinitis was possible. In January 1991, the veteran submitted his initial claim for service connection for a psychiatric disorder and a right wrist disability. He stated that his psychiatric disability was due to stress which was caused by an accident in service. Private medical reports show that the veteran was treated with medication for nasal congestion and drainage, and an irritated throat and wheezing in 1991. VA medical records show that the veteran was treated for various disorders and underwent examinations in the early 1990's. A report of outpatient treatment in February 1991 notes his complaints of nasal obstruction, post nasal drip and pressure in his ears. On examination, there was erythematous mucosa in his nose. The impressions included rhinitis. A report of his outpatient treatment in April 1991 notes that he had rhinitis that was exacerbated in the spring. It was noted that he had no history of headaches. Examination of his nose showed slight septal deviation to the left. The impression was allergic rhinitis. VA X-rays of the veteran's right wrist in April 1991 showed no abnormalities. It was noted that he was seen for right wrist pain. The veteran underwent VA examination in May 1991. He gave a history of injuring his right wrist when he fell on ice in service in February 1989. He related that he had been told that it was a sprain at that time, and no X-rays were taken of the right wrist. He said that he had recently been noticing more problems with his right wrist. He reported loss of motion in the right wrist and pain with a gripping movement and also during typing. He also described painful cramps in the right wrist and hand after writing for long periods. Also, he indicated that he had been noticing more problems since he had been using crutches. He said that the right wrist was weak and gave way, and that when he used the right wrist and hand for long periods of time he noticed some tingling sensation. Examination of the right wrist revealed tenderness over the middle of the dorsum of the wrist. Movements were painful and also limited beyond 50 degrees of dorsiflexion and beyond 70 degrees of palmar flexion. There were slightly decreased grip and strength noted in the right hand compared to the left. The veteran also reported having allergic rhinitis and stated that it was a perennial problem. It was noted that he had been taking medication and using an inhaler. On examination of the nose, sinuses, mouth and throat, there was tenderness over the maxillary sinuses. X-rays of the sinuses showed no evidence of acute sinusitis. X-rays of the right wrist showed no evidence of fracture or dislocation. The diagnoses included probable tendinitis of the right wrist, and no evidence of acute sinusitis at time of examination. It was noted that the veteran had a history of allergies. A report of the veteran's VA outpatient treatment in June 1991 notes that he was seen for allergic rhinitis that was being treated with medication and an inhaler. The veteran underwent VA psychiatric examination in July 1991. He gave a history of nightmares that began in 1987 and of sustaining injuries in an accident in service. On mental status examination, he had flight of ideas about hearing music, sad and happy music, and no one playing. He heard the call of his name at times. He complained of stress, nightmares, and depression at times. He reported suicidal ideation that he did not have the courage to carry out. He admitted to mood swings. The diagnosis was schizo-affective bipolar-type disorder. A summary of VA hospitalization in December 1991 shows that the veteran underwent lysis of the tendon sheath of the right wrist. It was noted that he underwent this surgery because he had an inflamed and edematous tendon sheath overlying the abductor pollicis longus and the extensor pollicis brevis tendons. The diagnosis was DeQuervain's tendinitis of the right wrist. Statements from the veteran and medical history reported by him on documents in 1991 and 1992 indicate that he had received psychiatric treatment at the Fallon Mental Health Clinic in Fallon, Nevada (which the RO had unsuccessfully attempted to obtain) and other treatment for the disorders being considered in this decision that were not of record. VA medical records show that the veteran was treated for various disorders in 1992, including his service-connected problems of the nose and throat. A report of his treatment in February 1992 notes that he was recently treated with medication for an upper respiratory infection and still had complaints of mild throat discomfort and cough productive of yellow sputum. On observation, there was slight drainage from his nose. He had positive maxillary sinus tenderness. The diagnosis was sinusitis. In March 1992, he was hospitalized for psychiatric treatment of situational anxiety and depression reaction. It was noted that he had a history of sinusitis. A report of treatment in June 1992 reveals that he had chronic knee problems and wore a knee brace and also used a cane. This report also shows that the veteran was treated for chronic sinus problems. In November 1992, he was seen for various problems, including sinus drainage of two weeks and a right wrist problem. His sinuses were not tender. The impressions included sinus allergy. The Board remanded the case to the RO in March 1993 for additional development. It was noted that the RO had unsuccessfully attempted to obtain reports of the veteran's treatment at the Fallon Mental Health Clinic in Fallon, Nevada, and had failed to obtain other reports of treatment reported by the veteran. The RO was advised, in part, to obtain a detailed list of all sources (VA or non-VA) of examination and treatment for a psychiatric disorder, a right wrist disorder, and rhinitis and sinusitis, during and after service, including those noted in previous correspondence. The veteran was requested to provide names and addresses of the medical providers, and dates of examination and treatment, in order to assist the RO in obtaining this information. VA medical reports show that the veteran was seen for various disorders in 1993 and 1994. In March 1993, he was seen for chronic rhinosinusitis. No significant problems were found on observation. In April 1993, he was seen for complaints of sinus problems with headache and a sore and aching right wrist. He stated that he had chronic sinus problems and that he then had a full-blown sinus infection. He had tenderness to percussion over the maxillary and frontal sinusitis. There was some drainage in the pharynx. The impression was upper respiratory infection with allergic component. He was treated with medication and advised to return to the clinic in three weeks. VA reports show that the veteran receives continuous treatment for rhinosinusitis. A report of treatment in March 1994 notes a history of rhinosinusitis with intermittent sinus infection. It was noted that his last sinus infection was two weeks ago and that he treated this problem with medication. He complained of burning and itching eyes. On observation, the right septum of his nose had some excoriation. There was some mucosa and it was inflamed. There were no abnormalities of the polyps or nasal discharge. The assessment was recurrent sinusitis that was treated with medication. A statement from the veteran's wife, dated in June 1994, notes that he was injured in a fall on ice in February 1989 while in service. She reported that the veteran sustained various injuries, including a right wrist injury. She reported that an Ace bandage was applied to the veteran's wrist at the clinic before the physician arrived on duty, and that the physician after reviewing X-rays found many injuries to be nonessential and only treated the essential injuries. In July 1994, the veteran notified the RO that he was unable to obtain medical reports from the Fallon Mental Medical facility. He submitted various VA reports of his treatment for psychiatric, right wrist, and sinus/rhinitis problems. The record shows that service connection is currently in effect for a left knee disorder, rated 20 percent; a low back disorder, rated 10 percent; tinnitus, rated 10 percent; external hemorrhoids, rated 10 percent; sinusitis and rhinitis, rated 10 percent; bilateral hearing loss, rated 10 percent; and adult acne with scarring on the face and neck, rated zero percent. The combined rating for the service-connected disabilities is 50 percent. II. Legal Analysis The veteran's claims are well-grounded, meaning they are plausible. A review of the record indicates that various reports of treatment for the disorders being considered in this decision were referred to in correspondence by the veteran and not of record, and the Board remanded the case to the RO in 1993 in order to obtain more specific information from him concerning this treatment, including the names and addresses of medical providers. The RO and the veteran have unsuccessfully attempted to obtain reports of treatment from the Fallon Mental Health Clinic in Fallon, Nevada, and the veteran has not provided more specific information concerning other treatment to enable the RO to obtain additional reports of his treatment. He did submit VA reports of treatment and this evidence has been considered in this appeal. Following the remand of this case by the Board to RO in 1993 and the subsequent development by the RO, I find that no further assistance to the veteran is required to comply with VA's duty to assist him. 38 U.S.C.A. § 5107(a) (West 1991). In order to establish service connection for a disability, the evidence must show the presence of it and that it resulted from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303. Service connection for a psychosis shall be presumed to have been incurred in service, even though there was no evidence of such disease during the period of service, if it became manifest to a degree of 10 percent within one year from date of termination of the veteran's active service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. A. Service Connection for a Psychiatric Disorder The veteran asserts that he was treated for a psychiatric disorder in service and the service medical records show that he was seen for possible drug dependency in August 1987, but at that time there was no evidence of a psychiatric disability. The service medical records do not indicate that he underwent further psychiatric evaluation or treatment, and the reports of his medical board examinations in 1989 do not show the presence of any psychiatric disorder. The post service records reveal that the veteran filed a claim for VA compensation in April 1990 and that he did not report any psychiatric problems at that time. These records indicate that the veteran did not file a claim for service connection for a psychiatric disability until January 1991, and a psychiatric disorder was not demonstrated until his VA psychiatric examination in July 1991. The July 1991 VA psychiatric examination shows a diagnosis of schizo-affective bipolar disorder, a psychosis, and he was treated for situational anxiety and depressive reaction during a period of VA hospitalization in March 1992. The evidence does not relate any of the psychiatric disorders found after service to an incident of service. While the veteran asserts that his current psychiatric disability is related to stress endured in service, including the trauma of sustaining injuries when he fell on ice in February 1989, his statements are not considered reliable evidence because he is a layman who does not have the expertise to make medical diagnoses or conclusions as to medical causation. Espirtu v. Derwinski, 2 Vet.App. 492 (1992). After consideration of all the evidence, the Board finds no reliable evidence of a psychiatric disorder in service or until July 1991, and no reliable evidence linking the veteran's psychiatric conditions found after service to an incident of service. Hence, the preponderance of the evidence is against the claim for service connection for a psychiatric disorder, and it must be denied. Since the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is inapplicable. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet.App. 49 (1990). B. Service Connection for a Right Wrist Disorder The service medical records show that the veteran was seen for a right fourth finger condition, but these records reveal no right wrist disorder nor was a right wrist disorder found at the time of his medical board examinations in 1989 prior to discharge from service. The report of his VA examination in June 1990 reveals that he had complaints of pain of the right fourth (ring) finger, but X-rays of the right hand found no abnormality. Nor was any abnormality found on examination of the right hand. At the May 1991 VA examination he gave a history of a right wrist injury when he fell on ice in service in February 1989, and examination of the right wrist revealed tenderness over the middle of the dorsum of the wrist. It was concluded that he probably had tendinitis of the right wrist. Later in 1991, he underwent lysis of the tendon sheath of the right wrist for DeQuervain's tendinitis of the right wrist at a VA hospital. The report of the veteran's December 1991 VA hospitalization indicates that the veteran underwent the right wrist surgery due to an inflamed and edematous tendon sheath overlying the abductor pollicis longus and the extensor pollicis brevis tendons that are tendons of the first digit (thumb) of the right hand, and none of the evidence of record links the veteran's current right wrist disorder with a tendon problem of the first digit of the right hand to his problems with the fourth finger of the right hand in service. Nor does the evidence link the veteran's current right wrist disorder to any other incident of service, including his fall on ice in February 1989. The veteran and his wife state that he fell on ice in service in February 1989 and sustained a right wrist injury. While the veteran and his wife are competent to make statements concerning the veteran's fall on ice in February 1989, and this evidence is considered reliable, their statements that a right wrist disorder was sustained in that injury are not credible because they are not corroborated by any medical evidence of a right wrist disorder until after the veteran's discharge from service. Also, the veteran's treatment in service for a right hand disorder, a problem with the fourth finger, was in 1988, prior to the accident in February 1989. Nor are the veteran and his wife competent to make medical diagnoses or conclusions as to medical causation. Espiritu, 2 Vet.App. 492. The Board recognizes the assertion of the veteran that the use of a cane for his service-connected left knee disorder aggravated his right wrist condition, but aggravation of a non-service- connected disorder by a service-connected disability is not a proper basis for secondary service connection. Leopoldo v. Brown, 4 Vet.App. 216 (1993). After consideration of all the evidence, the Board finds it is not in relative equipoise concerning the claim for service connection for a right wrist disorder. Thus, the veteran is not entitled to favorable resolution of this claim based on reasonable doubt. 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet.App. 49. The preponderance of the evidence is against the claim, and it must be denied. C. Increased Rating for Sinusitis and Rhinitis In order to establish entitlement to a higher rating for a service-connected disability, the evidence must show symptoms of the disorder that meet or more merely approximate the criteria for higher ratings under the applicable diagnostic codes in the Schedule for Rating Disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.7. A 10 percent evaluation is warranted for chronic atrophic rhinitis with definite atrophy of the infranasal structure and moderate secretion. A 30 percent evaluation requires moderate crusting, ozena (offensive-smelling discharge, Dorland's Illustrated Medical Dictionary 1117 (25th ed. 1974)), and atrophic changes. 38 C.F.R. § 4.97, Code 6501. A noncompensable evaluation is warranted for chronic pansinusitis with only X-ray manifestations and mild or occasional symptoms. A 10 percent evaluation requires moderate chronic pansinusitis manifested by a discharge, crusting or scabbing and infrequent headaches. A 30 percent evaluation requires severe chronic pansinusitis manifested by frequently incapacitating recurrences, severe and frequent headaches, and a purulent discharge or crusting reflecting purulence. 38 C.F.R. § 4.97, Code 6510. VA and private medical records show that the veteran receives occasional treatment for symptoms of rhinitis and problems with various sinuses. The VA report of February 1992 indicates treatment for maxillary sinus tenderness and the VA report of treatment in April 1993 indicates treatment for tenderness over the maxillary and frontal sinuses. His sinuses were normal at the time of his VA examination in June 1990, and VA X-rays of his sinuses at the time of examination in May 1991 showed no evidence of acute sinusitis. The report of the May 1991 VA examination, however, did note tenderness over the maxillary sinuses and a history of allergic rhinitis. Reports of his VA outpatient treatment since May 1991 indicate occasional problems with sinusitis and rhinitis manifested primarily by occasional nasal secretion, erythema, swelling, drainage, and tenderness. The evidence, however, does not show crusting, ozena, and atrophic changes due to rhinitis that produce moderate impairment in order to establish a rating of 30 percent under Diagnostic Code 6501. Nor does the evidence indicate the presence of pansinusitis manifested by frequently incapacitating recurrences, severe and frequent headaches, and a purulent discharge or crusting reflecting purulence that produce severe impairment in order to establish a rating of 30 percent under Diagnostic Code 6510. An extraschedular rating is not appropriate, as the evidence does not indicate that the veteran's sinusitis and rhinitis require treatment by frequent hospitalization or cause marked interference with employment. 38 C.F.R. § 3.321. After consideration of all the evidence, the Board finds that the veteran has a rhinitis/sinusitis disorder manifested by somewhat similar nasal and throat symptoms, and that one 10 percent rating for the rhinitis/sinusitis disorder best represents the veteran's disability picture. 38 C.F.R. §§ 4.7, 4.14. The evidence is not in relative equipoise concerning the claim for a higher rating for this disorder, and the veteran is not entitled to favorable resolution of this claim based on reasonable doubt. 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet.App. 49. The preponderance of the evidence is against the claim for an increased rating for the rhinitis/sinusitis disorder, and it must be denied. ORDER Service connection for a psychiatric disorder and a right wrist disability is denied. An increased evaluation for rhinitis and sinusitis is denied. Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991), a decision of the Board of Veterans' Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans' Judicial Review Act, Pub. L. No. 100-687, § 402 (1988). The date which appears on the face of this decision constitutes the date of mailing and the copy of this decision which you have received is your notice of the action taken on your appeal by the Board of Veterans' Appeals.