BVA9503617 DOCKET NO. 92-21 969 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Manchester, New Hampshire THE ISSUES 1. Entitlement to service connection for residuals of a fracture of the right hand. 2. Entitlement to service connection for residuals of a fracture of the left hand. 3. Entitlement to service connection for a disorder of the reproductive system. 4. Entitlement to service connection for residuals of a fracture of the left wrist. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Sandra L. Smith, Associate Counsel INTRODUCTION The veteran had active service from April 1982 to February 1988. This case is before the Board of Veterans Appeals (the Board) on appeal from a June 1992 rating decision which denied service connection for a left knee disorder, residuals of a tonsillectomy, residuals of a fracture of the right hand, residuals of a fracture of the left hand, and for a disorder of the reproductive system. The case was referred to the Regional Office (RO) for further development by the Board in a June 1994 remand. The requested development was accomplished and the rating decision of November 1994 continued the denial of service connection for residuals of a fracture of the left hand, residuals of a fracture of the right hand, and a disorder of the reproductive system. The RO granted service connection for a left knee disorder and for residuals of a tonsillectomy. The veteran and her representative have also raised the issue of service connection for residuals of a fracture of the left wrist. It appears from the record that this issue has been factually developed, thus the Board will assume jurisdiction of this issue as well for purposes of appellate review. The Board further determines that the veteran will suffer no prejudice from the assumption of this additional issue. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends that service connection is warranted for residuals of fractures of the left and right hands because both hands were injured while in service. In addition, it is contended that the veteran suffered a fracture of the left wrist during service. It is further contended that service connection is warranted for a disorder of the reproductive system because the veteran suffered numerous miscarriages during service and thereafter. The representative also asserts that the VA gynecological examination was inadequate and requests further medical evaluation. The representative also requests that any and all reasonable doubt be resolved in the veteran's favor. 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. Based on its review of the relevant evidence in this matter, 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 residuals of a fracture of the right hand, residuals of a fracture of the left hand, and a disorder of the reproductive system. It is the further decision of the Board that the evidence, giving the veteran the benefit of the doubt, warrants a grant of service connection for residuals of a fracture of the left wrist. FINDINGS OF FACT 1. All relevant available evidence necessary for an equitable disposition of the veteran's appeal has been obtained by the RO. 2. There is no evidence of any chronic disorder of the reproductive system in service. 3. There is no clinical evidence or medical opinion that any current reproductive disorder of the veteran's is related to any incident of service. 4. The in-service injuries to the veteran's various fingers were acute and transitory injuries with no chronic residuals. 5. There is no clinical evidence or medical opinion that any current hand disability is related to any incident of service. 6. It is reasonably probable that the veteran has residuals of an injury to the left wrist that occurred in service. CONCLUSIONS OF LAW 1. Residuals of a fracture of the left hand were not incurred in service. 38 U.S.C.A. §§ 1131, 5107 (West 1991); 38 C.F.R. § 3.303 (1994). 2. Residuals of a fracture of the right hand were not incurred in service. 38 U.S.C.A. §§ 1131, 5107 (West 1991); 38 C.F.R. § 3.303 (1994). 3. A chronic disorder of the reproductive system was not incurred in service. 38 U.S.C.A. §§ 1131, 5107 (West 1991); 38 C.F.R. § 3.303 (1994). 4. Residuals of an injury of the left wrist were incurred in service. 38 U.S.C.A. §§ 1131, 5107 (West 1991); 38 C.F.R. § 3.303 (1994). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS A person who submits a claim for benefits has the burden of submitting evidence sufficient to justify a belief by a fair and impartial individual that the claim is well grounded. 38 U.S.C.A. § 5107. After reviewing the evidence on file we conclude that the veteran's claims are well grounded within the meaning of 38 U.S.C.A. § 5107(a). That is, the claims presented are not inherently implausible. Furthermore, we conclude that all facts pertinent to the plausible claims have been developed and that as such, there is no further duty to assist in developing the claims as contemplated by 38 U.S.C.A. § 5107(a). The veteran's representative has raised the argument that the case should be remanded in order for the veteran to be afforded further medical evaluation. During the August 1994 gynecological examination the veteran gave a history of developing genital herpes in service after being raped. She also recounted that she had multiple miscarriages while in service and after discharge. She claimed that her six year old son was the result of her fourth pregnancy, and that she had been pregnant six times with five miscarriages. The representative contends that "a comprehensive work up should be performed in order that a determination can be made as to the etiology of the miscarriages and their relationship to the herpes complex." The Board has considered the representative's argument for further medical evaluation but has determined that further development is not necessary. The veteran was provided a thorough gynecological examination in August 1994 which diagnosed herpes by history. This diagnosis was confirmed by the VA general medical examiner in October 1994. She has also been diagnosed to have cervical dysplasia by history. A review of the veteran's service medical records disclosed no medical evidence of any miscarriages or of the presence of herpes during service. Thus, the Board concludes that the August 1994 examination was adequate and since, as explained below, the preponderance of the evidence is against service connection for herpes, whether or not there is any relationship between her current miscarriages and herpes is not relevant. The VA must determine whether the evidence supports the claims or is in relative equipoise, with the veteran prevailing in either case, or whether the preponderance of the evidence is against the claims, in which case, service connection must be denied. Gilbert v. Derwinski, 1 Vet.App. 49 (1990). Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1131. Service connection may also 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. 38 U.S.C.A. § 1113(b); 38 C.F.R. § 3.303(d). With chronic disease shown as such in service so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." Continuity of symptomatology is required where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). Service connection for a disorder of the reproductive system A review of the veteran's service medical records reveals that the service entrance examination, dated in March 1982, was negative for any female disorder. The "Report of Medical History" completed by the veteran at that time indicated that she had never been treated for any female disorder nor had a change in her menstrual pattern. The service treatment records show that in December 1982 the veteran reported to the emergency room complaining of vagina pain and discharge. She gave a history of "on and off sexual contact with 2 males." She expressed worry about herpes. Physical examination revealed normal looking external genitalia with some vaginal discharge. The cervix had mild cervicitis and whitish discharge. Cultures and smear were taken to rule out herpes. The laboratory report shows that the culture was negative for herpes. The diagnosis was vaginitis, nonspecific. A gynecology clinic report, dated in May 1983, indicated that the veteran gave a history of no pregnancies or children. Vaginitis was noted. A pap smear was performed and a prescription for birth control pills was given. A gynecology clinic report, dated in March 1984, indicated that the veteran gave a history of no prior pregnancies, miscarriages and abortions, or living children. The physical examination was normal except for a notation that the vagina was red. A pap smear was performed. The diagnostic assessment was Monilial vaginitis and Monistat was prescribed. A follow-up examination indicated that the March pap smear was negative and the physical examination was normal. In July 1984 a refill of the veteran's birth control pills was given. She was also prescribed Monistat vaginal cream. A gynecological questionnaire, apparently completed in 1985 as the veteran gave her age as 25 years old, indicated that the veteran had never had a pregnancy, delivery, or a miscarriage. She also indicated that she had no problems with her menstrual periods. The examination report noted a normal examination and that the veteran's prescription for birth control pills was refilled. A service examination report, dated in March 1986, revealed no disorders or disabilities. It was noted that a pelvic examination was performed. The veteran also completed a "Report of Medical History" in which she indicated that she had never been treated for a female disorder but had experienced a change in menstrual pattern. She also indicated that she was taking birth control medication. She denied a change in menstrual pattern in a "Report of Medical History" in September 1986. In November 1986 the veteran was seen for complaints of vaginal bleeding, intermittent since October 1986. Physical examination revealed no bleeding from cervix and no lesions. The fundus was tender to palpation and there was slight left adnexal tenderness. The diagnosis was dysfunctional uterine bleeding (DUB) and rule out pregnancy. A pap smear was taken and lab work ordered. The veteran returned one week later with continued complaints of intermittent vaginal bleeding and pelvic pain. Laboratory work was negative; the diagnosis remained DUB. An ultrasound was performed with negative results. She was then seen by a civilian physician and a dilation and curettage procedure ("D&C") was performed. The veteran was also prescribed Provera for this problem. In March 1987, during a thyroid follow-up examination, it was noted that she was taking Provera, 10 mg. A gynecological examination report, dated in March 1987 indicated that the veteran had experienced one past pregnancy but no past deliveries. She was not presently on birth control medication. She also indicated that she had never had an abnormal pap smear. The pelvic examination was normal and the pap smear results were negative. The veteran was instructed to discontinue Provera. In September 1987 the veteran reported with complaints of vaginal discharge. Her last menstrual period had been in July 1987. She denied spotting, bleeding, or pain. It was noted that the veteran was negative for gonorrhea, syphilis, herpes, pelvic inflammatory disease, and abnormal pap. Pelvic examination revealed no abnormalities of the external genitalia but the uterus was of increased size. The impression was that the veteran was pregnant, in the 9th week of gestation. In a referral noted to the social worker, it was noted that the veteran had two pregnancies but no deliveries. At 11 weeks gestation, the veteran completed an undated "screening questionnaire" in which she indicated that she had one prior pregnancy when she miscarried at 34 weeks. She also reported two prior pregnancies. A service separation examination report, dated in February 1988, showed that the veteran was currently pregnant, 30 weeks gestation. The veteran also completed a "Report of Medical History". She indicated that she was currently pregnant and believed she was in good health. She also stated that she had never been treated for a female disorder. The veteran was afforded a VA special gynecological examination in August 1994. The examination report noted that the veteran gave a history of being raped while in the service and that two weeks later she came down with a genital herpes infection. The veteran also related that she had multiple miscarriages while in the service and after discharge from service. She stated that she had been pregnant six times with five miscarriages. She has one child who was the result of her fourth pregnancy; however, he was born several weeks early. She had never been evaluated for causes of the recurrent miscarriage. She had no current complaints. She denied any vaginal discharge, however, she experienced herpes outbreaks approximately every six weeks lasting about five days. She stated that her periods had always been regular. Her last miscarriage was in June 1992. During the September 1994 examination the veteran also related that while in service she was told she was hypothyroid and started on Synthroid replacement; however, this was discontinued about six months later. In addition, she had had cervical dysplasia for which she had cryosurgery in 1984, 1989, 1990 and 1991. She reported she had had a pap smear six weeks earlier which reportedly was normal. Physical examination revealed normal appearing external genitalia with no current lesions. The uterus was normal without any evidence of prolapse. The cervix appeared to be intact without lesions. Both ovaries appeared to be normal. The diagnoses were: 1. Herpes simplex virus type II per patient history 2. Cervical dysplasia per patient history 3. History of multiple miscarriages with one pre-term delivery of a healthy child. Etiology of the miscarriages is not known. There could be multiple reasons for this, however, no workup has ever been undertaken to ascertain the cause, if cause can be found. 4. No evidence of thyroid disease. The veteran was afforded a VA general medical examination in October 1994. The examination report noted that the veteran related she developed herpes simplex while in service after being raped. She was also seeing two men at the time. Thereafter, she was treated symptomatically. She averaged four to five episodes per year secondary usually to stress. Examination of the external genitalia showed several small healing lesions over the vulva and labia. The diagnosis was: Herpes progenitalis secondary to herpes simplex. The Board finds, based on the evidence of record and the above legal criteria, that service connection is not warranted for a disorder of the reproductive system. The veteran has a current diagnosis of genital herpes which she claims began in service; however, the Board finds no evidence of herpes outbreaks in the veteran's service medical records from April 1982 to February 1988. A laboratory culture was performed in December 1982 but was negative for herpes. In September 1987 when the veteran was first diagnosed to be pregnant, it was noted that she was negative for herpes and other sexually transmitted diseases. There was no further mention of herpes in the service medical records. Herpes was first medically shown in 1994. Thus, service connection is not warranted for herpes. In addition, the veteran has a current diagnosis of cervical dysplasia which the veteran has claimed first occurred in 1984 while she was in service. However, a review of the medical records reveals no evidence of such disorder. The Board notes that all of the veteran's Pap smears were normal during service. In addition, there is no notation of a abnormal cervix during any of the pelvic examinations in the veteran's service medical records or in 1994. Thus, the Board finds that service connection is not warranted for cervical dysplasia. Furthermore, the Board notes that it can find no clinical evidence in the service medical records to support the veteran's claim of numerous miscarriages in service. The veteran was afforded regular examinations in the gynecological clinic during service. Contemporaneously recorded statements of the veteran during these examinations consistently showed that the veteran had no prior pregnancies, miscarriages, abortions, or births until the examination of March 1987. During that examination the veteran indicated that she had experienced one past pregnancy. Later, in 1987, the veteran completed a medical questionnaire and indicated that this prior pregnancy had ended in miscarriage at 34 weeks gestation. The Board finds it remarkable that evidence of such a late term miscarriage would not be noted in the veteran's medical records if it had actually occurred in service. The veteran was treated in the Fall of 1986 for dysfunctional uterine bleeding; however, there was no diagnosis of pregnancy. The Board concludes that the veteran had no chronic disorder of the reproductive system during service. The veteran was treated on several occasions during service for vaginitis; however, it cleared up each time with medication, leaving no residuals. Thus, there is no evidence of a chronic disorder during service. Furthermore, there is no evidence of numerous miscarriages during service in the service medical records and the Board finds the veteran's statements to that effect not credible. The Board also notes that her recent allegations of herpes in service are directly contradicted by the service medical records in December 1982 and September 1987. When she expressed concern about herpes in December 1982, she did not mention any rape as alleged in 1994. The veteran's history is inconsistent and her allegations are not credible. Therefore, the Board finds the preponderance of the evidence is against the veteran's claim for service connection for a disorder of the reproductive system. As such, the record does not present an approximate balance of positive and negative evidence with respect to the merits of the veteran's claim. Accordingly, the benefit of the doubt is not for application in this case. Service connection for left hand, right hand, and left wrist disorders A review of the veteran's service medical records reveals that the service entrance examination report, dated in March 1982, was negative for any hand or wrist disorder. Service treatment records show that in April 1983 the veteran reported to the emergency room complaining of trauma to her right hand. She gave a history of having caught her hand between an air tank and a wall earlier that day. Physical examination revealed mild edema and ecchymosis over the palmer 2nd and 3rd metacarpophalangeal (MP) joint. Range of motion was full but pain increased with movement. X-rays revealed no fracture or dislocation. The assessment was a contusion of the right hand. She was instructed to wear a splint for one weak. A radiological report, dated in November 1983, showed that the veteran's right hand was x-rayed following complaints of pain in the second and third MP joints after banging her hand. The report indicated that no fracture was seen. In February 1984 the veteran reported trauma to her left palm and right ulna while catching a softball. The assessment was contusion, and a radiological report, dated in February 1984, showed no fracture or dislocation of the left hand. The right ulna appeared normal. A radiological report, dated in December 1985 showed that the veteran's third finger of the right hand and fourth finger of the left hand were x-rayed to rule out rheumatoid arthritis. The report indicated that there was no significant radiographic abnormality demonstrated. A service medical examination report, dated in March 1986 was negative for any hand disorder, disability, or defect. However, in a "Report of Medical History" accomplished at the same time, the veteran indicated she had arthralgia in the fingers of both hands. In October 1986 x-rays of the left wrist were taken after the veteran reported that she slammed her wrist in a car door; no abnormalities were noted. The veteran was afforded a VA orthopedic examination in August 1994. The examination report indicated that the veteran gave a history of injuring both wrists in service in either 1983 or 1984 while playing softball. She stated that the left wrist was placed in a cast for 4-6 weeks and the right wrist was placed in a splint. Since then she has continued to have pain on lifting with the left with occasional swelling. The veteran also complained as to the right hand that she was unable to hold a pencil due to pain in the distal joint of the right thumb and that she had apparently lost some ability to flex the interphalangeal joint of the right thumb. The veteran's general health had been reasonably good. She had had one pregnancy which apparently was uncomplicated. She was presently working as a construction project manager. The physical examination by the VA orthopedist revealed loss of approximately 40 degrees of flexion in the interphalangeal joint of the thumb with moderate pain on attempting to pinch with the thumb and 30 degrees of flexion. Examination of the left wrist revealed some pain on full ulnar and radial deviation; however, there appeared to be a full range of flexion and extension. There was reasonably strong grasp. Possible slight anteroposterior laxity as compared to the "left" was noted, and there was also some tenderness over the scaphoid of the left wrist. X-ray of the left wrist was normal except for focal sclerosis along the medial aspect of the navicular bone which could be a normal variation versus an old healed nondisplaced fracture. X-ray of the right thumb was negative for any abnormality. The final diagnoses were: 1. Old tear, volar palate, interphalangeal joint, right hand 2. Question old fracture, scaphoid, left wrist The Board finds, based on the evidence of record and the above legal criteria, that service connection is warranted for residuals of a fracture of the left wrist. The veteran's service medical records show that in October 1986 x-rays were taken of the left wrist after the veteran reported slamming it in a car door. Although no abnormalities were noted at that time and the current x-rays are not definitive as to the presence of fracture residuals, the Board finds that, giving the veteran the full benefit of any reasonable doubt, it is reasonably probable that the veteran has current left wrist pathology which is related to that in-service injury. Thus, service connection for residuals of an injury to the left wrist should be granted. The Board further finds that service connection is not warranted for either a left hand or right hand disorder. The veteran's recent VA examination disclosed residuals of an old tear of the interphalangeal joint of the right thumb. However, a review of the service medical records revealed no evidence of any thumb injury. Although the veteran did have several injuries to individual fingers of both hands in service, contemporaneous x- rays revealed no abnormalities. Furthermore, the service separation examination was negative for any hand disorder or disability, there is no medical evidence of continuity of symptomatology and the recent VA orthopedic examination revealed no current pathology except for the right thumb abnormality. Thus, the Board concludes that the preponderance of the evidence is against the veteran's claim for service connection for bilateral hand disorder. As such, the record does not present an approximate balance of positive and negative evidence with respect to the merits of these issues. Accordingly, the benefit of the doubt is not for application to them. ORDER Service connection for residuals of an injury of the left wrist is granted. Service connection for a disorder of the reproductive system is denied. Service connection for residuals of a fracture of the right hand is denied. Service connection for residuals of an injury of the left hand is denied. (CONTINUED ON NEXT PAGE) HOLLY E. MOEHLMANN 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.