BVA9503555 DOCKET NO. 93-10 087 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Milwaukee, Wisconsin THE ISSUES 1. Entitlement to secondary service connection for degenerative arthritis in the cervical and lumbar spine. 2. Entitlement to secondary service connection for peptic ulcer disease with active duodenal ulcer. 3. Entitlement to a disability evaluation in excess of 40 percent for residuals of gunshot wound of the right shoulder, Muscle Groups I and III, with fracture of the clavicle, healed, with excessive callus (major extremity). 4. Entitlement to a disability evaluation in excess of 40 percent for residuals of gunshot wound, Muscle Group VII with injured flexor, loss of grip, and destruction of interphalangeal joint, right thumb (major extremity). 5. Entitlement to a disability evaluation in excess of 30 percent for generalized anxiety disorder. 6. Entitlement to a disability evaluation in excess of 10 percent for disfiguring gunshot wound scars of the left forehead. 7. Entitlement to a total disability rating on the basis of individual unemployability. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD Christopher B. Moran, Counsel INTRODUCTION The veteran served on active duty from August 1943 to December 1945. Since the issue of entitlement to service connection for a spine disorder was previously denied by the Board of Veterans' Appeals (Board) in April 1980 solely on a direct and presumptive basis, the current issue of entitlement to secondary service connection for arthritis of the cervical and lumbar spine has been developed on a de novo basis by the Department of Veterans Affairs (VA) Regional Office (RO). Also, since it appears from the veteran's most recent substantive appeal filed in January 1993 that he may be raising issues of whether there is new and material evidence to reopen claims of entitlement to service connection for hearing loss and a bilateral knee disorder (previously denied by the Board in April 1980) as well as entitlement to service connection for post-traumatic stress disorder (PTSD) such matters are referred to the RO for appropriate action. It should be noted, however, that a claim for service connection for PTSD would be moot because service connection has already been established for a generalized anxiety disorder, and that disability and PTSD are rated on the basis of the same schedular criteria. Also, we note that while the issue of entitlement to a total disability rating on the basis of individual unemployability was withdrawn at a personal hearing before a hearing officer at the RO in September 1992, the appellant and his representative have subsequently continued to present arguments with respect to such issue and, therefore, it remains as an issue on appeal. In this regard, it is noteworthy that the withdrawal of a notice of disagreement or substantive appeal must be in writing. 38 C.F.R. § 20.204 (1994). The Board recognizes that while this case was at the Board additional evidence was submitted by the veteran along with a claim of entitlement to service connection for an ulcer disorder secondary to service-connected anxiety disorder. These are also referred to the RO for appropriate action. REMAND Following a preliminary review of the record, the Board is of the opinion that the medical evidence currently on file is insufficient for resolving all of the underlying medical issues to enable the Board to render a legal determination with respect to all of the issues on appeal. Colvin v. Derwinski, 1 Vet.App. 171 (1991). Specifically, we note that the veteran argues that he developed an ulcer secondary to aspirin and other similar medication for treatment of pain associated with musculoskeletal disorders including service-connected residuals of gunshot wound of the right shoulder, Muscle Groups I and III, with fracture of the clavicle, healed, with excessive callus (major extremity) and residuals of gunshot wound, Muscle Group VII with injured flexor, loss of grip, and destruction of interphalangeal, right thumb (major extremity). The Board notes that in view of the long history of the veteran's gastrointestinal symptoms associated with aspirin and other medications for pain resulting from his service-connected musculoskeletal disabilities, he should undergo an examination by a gastroenterologist to determine the nature and etiology of any gastrointestinal disorder, including peptic and duodenal ulcer disease It also appears that there are outstanding pertinent records of treatment at a VA pain clinic as well as records of treatment for stomach ulcer in the 1960's, including the report of an upper gastrointestinal series at Zablocki VA Medical Center, as reported by the veteran as history on a VA examination in September 1991. Such records were not available to the examiner at that time. Moreover, the Board notes that in view of the fact that the veteran was not provided a psychiatric examination by a psychiatrist in November 1992, an examination by a specialist in psychiatry with supplemental psychological testing to determine the extent and degree of severity associated with his service- connected generalized anxiety disorder would be helpful in addressing that claim for increase. In view of arguments that the veteran's service-connected disfiguring gunshot wound residual scars of the left forehead are manifested by discoloration and other color contrast deformities warranting a higher disability rating, an examination by a specialist in dermatology, including unretouched color photographs of the affected area, to determine the extent and degree of severity associated with the service-connected disorder would also be helpful. Special consideration should be given to the note provisions under 38 C.F.R., Part 4, Diagnostic Code 7800, pertaining to discoloration of disfiguring scars of the head, face or neck. Under the circumstances of this case, the Board is of the opinion that additional assistance is required. Accordingly, the case is REMANDED to the RO for the following: 1. The RO should contact the veteran and obtain detailed information regarding the names and addresses of all private and VA medical providers and dates of pertinent treatment for peptic ulcer disease, including active duodenal ulcer, at any time since his separation from service. Thereafter, the RO should make all necessary arrangements to obtain copies of all pertinent records of treatment from the sources named by the veteran, to include all records of treatment through the VA pain clinics noted in the record, as well as records of treatment for a stomach ulcer and an upper gastrointestinal series in the 1960's at Zablocki VA Medical Center. Any data obtained should be associated with the claims folder. 2. The veteran should be afforded a comprehensive examination by a gastroenterologist to determine the nature and etiology of any gastrointestinal disorder he may have, including peptic ulcer disease with active duodenal ulcer. The examiner should comment specifically on whether there is a causal relationship between any currently identified ulcer and aspirin or other medication prescribed for the veteran's service-connected residuals of a gunshot wound of the right shoulder. If any other medication is considered to be the cause of a gastrointestinal disorder (including ulcer disease), the disability requiring the prescription should be specifically identified. All appropriate tests should be undertaken and the veteran's claims folder, to include all records requested in the preceding paragraphs, should be made available to the examiners for their review prior to consultation with the veteran. 3. The veteran should be afforded an examination by a specialist in dermatology in order to determine the current severity of his gunshot wound residual disfiguring scars of the left forehead. The examination should include unretouched color photographs of the affected areas. The examination should be conducted in accordance with pertinent provisions of the VA Physician's Guide for Disability Evaluation Examinations. 4. The veteran should be accorded a comprehensive VA examination by a psychiatrist, with a supplemental formal battery of psychological testing, to determine the current severity of his service-connected generalized anxiety disorder. The psychiatric examiner should place the veteran on the Global Assessment of Functioning Scale (GAF) provided in American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, along with an explanation of the numerical score assigned. The psychological testing results should be given to the psychiatric examiner prior to the psychiatric examination. The veteran's claims folder must be made available to (and reviewed by) the examiner prior to the evaluation. 5. The veteran should be accorded an examination by a specialist in orthopedics to determine the current severity of his service-connected residuals of gunshot wounds of the right shoulder, Muscle Groups I and III, with fracture of the clavicle with excessive callus (major extremity) and residuals of gunshot wound of the right hand (Muscle Group VII) with injured flexor, loss of grip and destruction of interphalangeal joint, right thumb (major extremity). All indicated studies should be undertaken and all functional impairment resulting from these wounds should be reported in detail. 6. Each examination should be conducted in strict compliance with all pertinent chapters and sections in the VA's Physician's Guide for Disability Evaluation Examinations. Each examiner should furnish a comprehensive report with attention to the history of the veteran's disability and detailed account of pathology found to be present. 7. The RO should formally adjudicate the issue of entitlement to service connection for peptic ulcer disease with active duodenal ulcer secondary to service- connected generalized anxiety disorder. When this development is completed, the RO should review the issues on appeal with consideration of the total history of the service-connected disorders at issue for increased ratings as well as all potentially applicable regulations as discussed in Schafrath v. Derwinski, 1 Vet.App. 589 (1991). Moreover, the issue of entitlement to a total disability rating based on individual unemployability should be considered in light of the pertinent factors discussed in Hatlestad v. Derwinski, 3 Vet.App. 213 (1992) and Moore v. Derwinski, 1 Vet.App. 356 (1991). If any benefit sought on appeal is not granted, the appellant and his representative should be furnished a supplemental statement of the case with regard to the additional development, to include all evidence added to the record since the supplemental statement of the case issued in January 1993 and the rationale for all action taken. The veteran should be notified of the importance of submitting a notice of disagreement and substantive appeal where applicable regarding issues not previously certified in order for appellate consideration. The veteran and his representative should be granted a reasonable opportunity to respond before the record is returned to the Board, if in order, for further appellate review. The purpose of this REMAND is to procure additional clarifying information. No action is required of the veteran until he receives further notice. GEORGE R. SENYK 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. 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).