BVA9504166 DOCKET NO. 91-13 670 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Albuquerque, New Mexico THE ISSUES 1. Entitlement to service connection for cardiovascular disability. 2. Entitlement to a compensable rating for bilateral hearing loss. 3. Entitlement to an increased rating for peptic ulcer disease with hiatal hernia and gastritis, currently rated as 10 percent disabling. 4. Entitlement to an increased rating for post-traumatic stress disorder (PTSD), currently rated as 10 percent disabling. 5. Entitlement to a total rating based on unemployability due to service-connected disabilities. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Nancy S. Kettelle, Counsel INTRODUCTION The veteran served on active duty from December 1954 to October 1979. This matter initially came to the Board of Veterans' Appeals (Board) on appeal from an October 1988 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Honolulu, Hawaii. During the course of the appeal, the veteran moved to New Mexico, and the RO in Albuquerque, New Mexico, has handled the case since that time. REMAND In the June 1993 remand, the Board noted that the veteran had raised the issue of entitlement to service connection for diverticula of the colon and requested that the RO develop and adjudicate that claim. Also, the Board requested that the RO evaluate the veteran's service-connected varicose veins of the right leg and thigh and, if indicated, readjudicate the veteran's claim for service connection for migraine with visual disturbance on a secondary basis. In a May 1994 rating decision, the RO denied service connection for diverticula of the colon and service connection for migraine headaches with visual interference and an increased rating for varicose veins of the right leg and thigh. The Board construes the October 1994 statement from the veteran's representative as the veteran's Notice of Disagreement with respect to these issues. Due process requires that the veteran be provided a statement of the case prior to consideration of these issues by the Board. Review of the record shows that at a July 1993 VA examination for diseases of the arteries and veins, the physician noted there was incompetence of the right greater saphenous vein and diagnosed the veteran as having right greater saphenous vein varicosities. The physician stated that the veteran needed ligation/excision of the right greater saphenous vein or support hose. A later entry in the record shows that the veteran was admitted to the general surgery service at the Albuquerque VA Medical Center for treatment of varicosities in September 1993. The hospital discharge summary, any operation report and any follow-up outpatient records are not included in the record and should be obtained. Among the veteran's claims is entitlement to service connection for diverticula of the colon. The veteran has pointed out that his service medical records show that diverticula were identified during gastrointestinal studies in May 1979. In August 1993, the veteran underwent a flexible sigmoidoscopy and a colonoscopy at the Albuquerque VA Medical Center. Those procedures disclosed diverticula in the sigmoid, transverse, and descending colon. The impression following the sigmoidoscopy was internal hemorrhoids; mild diverticulosis; and sigmoid polyps. The impression following the colonoscopy was colorectal polyps and internal hemorrhoids. In the August 1993 report of a VA "for stomach" examination, a physician who cosigned the colonoscopy report noted that two polyps had been excised during the colonoscopy but that no diverticula were seen. He stated that those reported on X-ray may well have been circular abnormalities due to polyps. In view of this conflicting information, the Board is of the opinion that further development should be undertaken and a medical opinion obtained as to the presence of diverticula of the colon and their relationship, if any, to diverticula identified in service. As noted above, hemorrhoids were found during the August 1993 sigmoidoscopy and colonoscopy procedures. The veteran's service medical records show that hemorrhoids were noted at the his October 1979 separation examination. The veteran has not claimed service connection for hemorrhoids; the RO should clarify whether the veteran wishes to do so. At the July 1993 VA psychiatric examination, a board of two psychiatrists diagnosed the veteran as having severe, incapacitating PTSD; chronic dysthymia; and episodic major depression. The psychiatrists specifically stated that they considered the veteran's chronic dysthymia and major depression episodes to be a direct result of his PTSD. This raises the issue of secondary service connection for dysthymia and major depression which should be adjudicated by the RO. In view of the delay introduced by the need for an additional remand, the Board is of the opinion that additional contemporaneous examinations concerning the veteran's bilateral hearing loss disability, his peptic ulcer disease with hiatal hernia and gastritis as well as his psychiatric disability would facilitate its decision on the increased rating and total rating claims. See Littke v. Derwinski, 1 Vet.App. 90 (1990). Accordingly, the case is REMANDED to the RO for the following actions: 1. The RO should obtain and associate with the claims file all outpatient treatment records, hospital summaries and operation reports for the veteran from the VA Medical Center in Albuquerque, New Mexico, dated from August 1993 to the present, to include any hospital summary, operation report, and follow-up outpatient treatment related to hospitalization in September 1993 for treatment of varicosities. 2. The RO should contact the veteran and request that he clarify whether he wishes to claim entitlement to service connection for hemorrhoids. The RO should also request that the veteran identify the names, addresses, and approximate dates of treatment for all health care providers who have treated him at any time since service for any disability for which he is currently seeking service connection or who have recently treated him for any service-connected disability. With any necessary authorization from the veteran, the RO should attempt to obtain copies of treatment records identified by the veteran which have not been secured previously. 3. The RO should again request that the veteran complete and return an up-to-date education and employment statement, VA Form 21-8940. 4. The RO should arrange for a VA examination of the veteran by a board certified gastroenterologist, if available, to determine the nature and extent of the veteran's service-connected peptic ulcer disease with hiatal hernia and gastritis, the nature and extent of any diverticula of the colon, and, if the veteran is claiming service connection for hemorrhoids, the nature and extent of any hemorrhoids. All indicated studies should be performed, and the claims folder should be made available to the physician prior to the examination. The physician should be requested to provide an opinion, with complete rationale, as to the relationship, if any, between any diverticula of the colon found on current examination and diverticula in the sigmoid area identified in service in May 1979. In addition, if the veteran is seeking service connection for hemorrhoids, the physician should be requested to provide an opinion, with complete rationale, as to the relationship, if any, between any hemorrhoids found on current examination and the hemorrhoids noted at the veteran's service separation examination in October 1979. The physician should also be requested to comment on the impact of the veteran's peptic ulcer disease with hiatal hernia and gastritis on his ability to work. 5. The RO should arrange for a VA audiology examination of the veteran to determine the nature and extent of the veteran's service-connected bilateral hearing loss. All indicated studies should be performed. The audiologist should also be requested to comment on the impact of the veteran's hearing loss on his ability to work. The claims folder should be made available to the audiologist prior to the examination. 6. The RO should arrange for a VA examination of the veteran by an appropriate specialist to determine the nature and extent of his service-connected varicosities, right leg and thigh. The physician should also be requested to comment on the impact of the varicosities on the veteran's ability to work. All indicated studies should be performed, and the claims folder should be made available to the physician prior to the examination. 7. The RO should arrange for a VA examination of the veteran by a board certified psychiatrist, if available, to determine the nature and extent of his PTSD as well as any dysthymia and major depression. All indicated studies should be performed, and the claims folder should be made available to the psychiatrist prior to the examination. The examiner should be requested to provide a Global Assessment of Functioning score for the veteran with an explanation of the significance of the score provided. The psychiatrist should also be requested to offer an opinion as to the degree of social and industrial impairment the veteran experiences as the result of his PTSD, dysthymia and major depression. 8. Then, the RO should undertake any other indicated development. 9. Then, if the veteran is seeking service connection for hemorrhoids, the RO should adjudicate the claim. If the claim is denied, the RO should inform the veteran, and notify him of his appellate rights with respect to this issue. 10. The RO should also adjudicate the issue of entitlement to service connection for dysthymia and major depression secondary to PTSD. If this claim is denied, the RO should inform the veteran, and notify him of his appellate rights with respect to this issue. 11. In addition, the RO should, in light of the evidence obtained pursuant to the requested development, readjudicate the issues of entitlement to service connection for diverticula of the colon, entitlement to service connection for migraine headaches with visual interference and entitlement to an increased rating for varicose veins of the right leg and thigh. The RO should also readjudicate entitlement to service connection for cardiovascular disability, entitlement to a compensable disability rating for bilateral hearing loss, entitlement to an increased rating for peptic ulcer disease with hiatal hernia and gastritis, and entitlement to an increased rating for PTSD (with consideration of the effects of dysthymia and major depression if secondary service connection has been granted for these disabilities). Finally, unless it has become moot, the RO should readjudicate the issue of entitlement to a total rating based on unemployability due to service- connected disabilities. 12. If the benefits sought on appeal, including service connection for diverticula of the colon and migraine headaches with visual interference and an increased rating for varicose veins of the right leg and thigh, are not granted to the veteran's satisfaction or if a timely notice of disagreement is received with respect to any other matter, the RO should issue a Supplemental Statement of the Case for all issues in appellate status and inform the veteran of any issue with respect to which further action is required to perfect an appeal. The veteran and his representative should be provided an opportunity to respond. Thereafter, the case should be returned to the Board for further appellate consideration, 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 otherwise notified by the RO. SHANE A. DURKIN Member, Board of Veterans' Appeals (CONTINUED ON NEXT PAGE) 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. 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) (1994).