BVA9406556 DOCKET NO. 92-10 507 ) DATE ) ) ) ` THE ISSUES 1. Entitlement to an increased rating for service-connected chronic obstructive pulmonary disease (COPD), with bronchitis and residuals of pneumonia, currently rated as 10 percent disabling. 2. Entitlement to an increased (compensable) rating for service- connected residuals of an infection to the palate of the mouth. 3. Entitlement to an increased (compensable) rating for service- connected athlete's foot. 4. Entitlement to service connection for post-traumatic stress disorder (PTSD). 5. Entitlement to service connection for pain at the back of the neck and on the sides of the head. 6. Entitlement to service connection for a positive tuberculosis tine test. 7. Entitlement to service connection for a sinus disorder, to include sinusitis and vasomotor rhinitis. REPRESENTATION Appellant represented by: Military Order of the Purple Heart WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD L. L. Gann, Associate Counsel REMAND The veteran contends that he suffers from multiple conditions which were incurred in, or are attributable to service. In light of the complicated nature of the issues presented in this case, a procedural overview is necessary for appropriate clarification of the claims on appeal. In a May 1990 rating decision, the Boise, Idaho, regional office (RO) considered entitlement to service connection for 9 different issues, awarding service connection for bronchitis with residuals of pneumonia (changed by a rating decision dated in July 1990 to include COPD), athlete's foot, and residuals of an infection to the palate of the mouth. Service connection was denied, however, for a positive TB tine test, numbness of the fingers, vasomotor rhinitis, sinusitis, chest pain and pain in the back of the neck and the sides of the head. The veteran filed a notice of disagreement with this decision, contesting both the schedular disability ratings awarded for his service-connected conditions and the denial of service connection for his other claims. The May 1990 rating action also noted claims for service connection for a below-the-knee amputation of the leg secondary to synovial carcinoma of the left heel, asthma, degenerative arthritis, a nervous condition, and a rash, all claimed as secondary to exposure to Agent Orange in service. The RO deferred consideration of these claims, however, pending revision of the regulations regarding service connection for disabilities secondary to Agent Orange. In July 1990, the RO also denied service connection for post- traumatic stress disorder (PTSD). In September 1990, the veteran filed a substantive appeal, contesting the denial of service connection for PTSD, sinusitis and chest pain, as well as the schedular rating for his service-connected residuals of an infection to the palate of the mouth. He also claimed that his asthma was secondary to service-connected COPD, rather than secondary to Agent Orange exposure. In his appeal, he also indicated that his claim for service- connection for numbness of the fingers was part of a general claim for peripheral neuropathy secondary to Agent Orange exposure. In light of this assertion, further development and adjudication of this issue was deferred, to be addressed with the other claims for service connection secondary to Agent Orange exposure as was the issue of entitlement to service connection for osteoporosis secondary to Agent Orange exposure. By way of a supplemental statement submitted in April 1991, he also raised the issue of entitlement to service connection for an ulcerated pylorus, claimed as secondary to Agent Orange exposure or secondary to the service-connected residuals of an infection to the palate. These issues have also not been adjudicated by the RO. In a May 1991 hearing held before a hearing officer of the Department of Veterans Affairs (VA), the veteran indicated that his chest pains were symptoms associated with his service-connected respiratory disability, rather than a separate cardiovascular disability, as previously rated by the RO. The issue of separate service connection for these chest pains was, therefore, considered withdrawn from appeal. A supplemental statement of the case informing the veteran of this action was issued in October 1991. In November 1991, service connection was awarded by decision of the Office of the Secretary for Veterans Affairs for the below-the-knee amputation of the veteran's left leg secondary to synovial sarcoma, found to be the result of exposure to Agent Orange in service. The RO granted a 40 percent rating for this disability in December 1991, which has not been contested by the veteran. In light of the aforementioned history, we find that the issues properly before us on appeal consist of entitlement to increased ratings for service-connected COPD, residuals of a palate infection and athlete's foot, as well as entitlement to service-connection for a positive TB tine test, a sinus disorder, head and neck pains and PTSD. The veteran first contends that he warrants an increased rating for his service-connected COPD, with bronchitis and residuals of pneumonia. We note that inasmuch as the veteran has not been afforded a VA pulmonary examination, to include appropriate testing, since May 1990, the current status of this condition is unclear. Moreover, in October 1991, Dr. Covelli, a private physician, submitted a letter indicating that the veteran's pulmonary condition has increased in severity, and contributes to his physical incapacity. We also note that the veteran has not been afforded examinations for his service-connected residuals of an infection to the palate of the mouth or his service-connected athlete's foot since May 1990. He contends that his residuals of a palate infection directly contribute to sinus and dental problems. He also asserts that his athlete's foot condition is misdiagnosed inasmuch at is not limited to his right foot, but also affects various areas of his lower extremities. In light of these contentions, we believe that a current examination is warranted to determine the current status of these disabilities. The veteran also contends that he is entitled to service connection for PTSD. The record contains an April 1990 note from F. Garza, a team leader at the Midland Texas Veteran's Center, who indicates that the veteran had exhibited PTSD symptomatology since November 1989, when he first reported to the center. These records have not been obtained and associated with the claims folder. We note that his most recent VA examination dated in May 1990 gave a diagnosis of PTSD and psychosomatic disorder. The bases for these conclusions were not specified, but were presumably based upon symptomatology such as feelings of anxiety, anger, frustration and sleep disturbances. Moreover, the examiner did not indicate the nature of the veteran's specific stressful events in service which could give rise to the diagnosis of PTSD. The veteran has been requested to furnish a list of specific stressful or traumatic events in service to which he attributes his PTSD. He has not, however, specifically responded to this request, although he has provided information in his VA examinations concerning his alleged service in Vietnam. Service personnel records concerning his duty assignments indicate foreign sea duty from December 1970 to March 1972. These records do not, however, specify the locations and nature of the veteran's duties. With regard to the veteran's claims of entitlement to service connection for degenerative arthritis, osteoporosis, peripheral neuropathy, an ulcerated pylorus and a rash, secondary to Agent Orange exposure, we note that V.B.A. Circular 24-94-1 (February 15, 1994), now provides the appropriate procedures by which claims based on exposure to Agent Orange are to be processed. The RO is therefore instructed to render appropriate development and adjudication on these issues based upon the Secretary's directions. Furthermore, the issues of service connection for asthma, claimed as secondary to his service-connected pulmonary disability, and an ulcerated pylorus, claimed as secondary to the service-connected infection of the palate, should also be properly developed and adjudicated. In light of the foregoing, this case is REMANDED for the following: 1. The RO should attempt to determine whether the veteran engaged in combat during service and/or was exposed to other unusual or life- threatening situations. The veteran should be contacted and requested to provide specific information concerning the incidents or stressors during service which resulted in his claimed PTSD. In this regard, the veteran should be advised of the importance of responding to this request. The information should include a detailed description of the circumstances, the dates and locations where any such incident occurred, including the units to which he was assigned, and the names of any individuals involved. After this information is obtained from the veteran, it should be provided to the United States Army and Joint Services Environmental Support Group(ESG), 77998 Cissna Road, Springfield, VA 22150 for verification. 2. The RO should contact the Midland Vet Center, 2404 West Illinois Avenue, Midland, Texas 79703, to obtain all treatment and evaluation records for the veteran since November 1989. These records should thereafter be associated with the claims folder. 3. The RO should obtain from the Social Security Administration a copy of the Administrative Law Judge's decision awarding disability benefits in March 1991, together with the supporting documents, medical and otherwise, which served as the basis for the award. 4. The RO should arrange for the veteran to be examined by specialists in pulmonary medicine, dermatology, ENT (ears, nose and throat) and psychiatry. The specialist in pulmonary medicine should determine and discuss the current nature and extent of the veteran's pulmonary disability, diagnosed as COPD with bronchitis and residuals of pneumonia. All appropriate tests, including chest x-rays, pulmonary function studies and arterial blood gas studies, should be performed. The examiner should provide an interpretation of the results of the tests performed. The dermatologist should discuss the current status of the veteran's service-connected athlete's foot, particularly noting the extent, severity, history and etiology of any current findings. The specialist in ENT should perform an examination to determine the current nature and extent of the veteran's residuals of an infection to the palate of the mouth. The psychiatrist should perform a comprehensive examination of the veteran to determine the nature of any psychiatric disorder noted, to include a specific discussion of any symptomatology and manifestations attributable to PTSD, if found. It is essential that the results of the development undertaken in paragraph 1 above, including the report for the ESG, be provided the examiner prior to the evaluation. The examining physician should be instructed to discuss all stressful events to which any diagnosis of PTSD is attributed. The applicable provisions of The Diagnostic Criteria from DSM-111-R should be discussed and a multi- axial diagnosis rendered. The examiners should have all pertinent medical records available for review, and the results of prior examinations must be carefully coordinated so that a comprehensive assessment with respect to the impact of the veteran's disabilities may be ascertained. Physician's Guide for Disability Evaluation Examinations (IB II-56), Section 1.8 (1985). 5. When the examinations have been completed, the RO should review the reports to determine their sufficiency for adjudication. Any report found inadequate should be returned to be supplemented by additional examination and/or elaboration. When this development has been completed, the RO should readjudicate the issues of increased ratings for service-connected COPD, residuals of an infection to the palate, and athlete's foot, as well as service connection for PTSD. Should the decision remain adverse to the veteran, he and his representative should be furnished a supplemental statement of the case and afforded a reasonable opportunity for reply. The remaining issues of service connection for a sinus disorder, a positive TB tine test and head and neck pain will be held in abeyance pending the RO's adjudication of the other claims. Therefore, regardless of the RO's decision on remand, the case must be returned to the Board of Veterans' Appeals so that we may consider the other issues on appeal. The purpose of this REMAND is to comply both with our duty to assist the appellant in developing his claim, and our duty to afford due process in the adjudication of his claims. BOARD OF VETERANS' APPEALS WASHINGTON, D.C. 20420 W. H. YEAGER, JR., M.D. BETTINA S. CALLAWAY JACK W. BLASINGAME Under 38 U.S.C.A. § 7252 (West 1991), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Veterans Appeals. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (1993).