BVA9501859 DOCKET NO. 94- 02 150 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUES 1. Entitlement to service connection for a left knee disorder. 2. Entitlement to service connection for an acquired psychiatric disorder to include post-traumatic stress disorder (PTSD). 3. Entitlement to service connection for asthma. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD J. F. Gussio, Associate Counsel INTRODUCTION The veteran had active military service from November 1967 to October 1969. This appeal to the Board of Veterans' Appeals (Board) arises from an April 1993 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Chicago, Illinois. The veteran's claim for service connection for residuals of exposure to Agent Orange has not been developed for appellate review and is referred to the RO for appropriate action. REMAND The veteran, in effect, contends that service connection for an acquired psychiatric disorder to include a diagnosis of PTSD is warranted. The service medical records reveal no clinical complaints or findings for a psychiatric disorder in service. However, private treatment records dated in March 1970, reveal schizophrenia, latent type, was diagnosed within one year after separation of service. It was also noted that the veteran was a mental patient at "Omaha" prior to service in 1962. In a private physician statement dated in November 1992, major depression, PTSD, and alcohol dependence were diagnosed. When the veteran was examined by the VA in December 1992, the diagnosis was PTSD. The veteran testified that he experienced life threatening stressors while in Vietnam. He testified that he was a truck driver near a combat zone in Vietnam; that he witnessed deaths and injured soldiers when he delivered supplies to the front lines; that he witnessed North Vietnamese being tortured when they were interrogated; and that he was in fear of his life around the combat zones. The Board is of the opinion that the veteran's testimony is plausible, but the stressors identified by the veteran have not bee verified. Moreover, additional development is needed to clarify the veteran's disability picture. Addressing the veteran's claim for service connection for asthma, the veteran denied having asthma on the entrance examination in October 1967. Clinical evaluation revealed no clinical findings or complaints of asthma. On the Medical Board examination in September 1969, the veteran reported having a life long history of asthma. Asthma, existing prior to entrance, was diagnosed. When the veteran was examined by the VA in December 1992, the diagnoses were asthma and chronic pulmonary obstructive disease. The veteran is entitled to the presumption of soundness except for defects noted on induction examination. Clear and unmistakable evidence is required to rebut the presumption. 38 U.S.C.A. § 1111. Here, asthma was not noted on the entrance examination, but the veteran was later discharged for asthma existing prior to service. The Board is of the opinion that further development is warranted to clarify whether asthma pre- existed service. Finally, the veteran's service medical records appear to be incomplete. In an August 1970 rating action, the RO referred to a neurological screening report prepared in service that is not of record. The rating action stated that an unstable personality was the diagnosis noted on that report. To ensure that VA has met its duty to assist the appellant in developing the facts pertinent to his claims, the case is REMANDED to the RO for the following development: 1. The RO should perform an exhaustive search for the veteran's service medical records, including the neurological screening report referred to in the 1970 RO rating action. If any records have been lost or destroyed, this should be verified. All records obtained should be associated with the veteran's claims file. 2. The RO should contact the veteran and request him to identify all doctors/institutions [names, addresses, etc.] who treated him for either a mental disorder or asthma prior to entering service in November 1967 and the approximate dates of such treatment. Any records identified by the veteran should be obtained by the RO and associated with his claims file. The RO should provide written medical releases to be executed by the veteran for this purpose. 3. The RO should contact the veteran to obtain any additional information [names, dates, locations, unit assignments] that would help identify the claimed stressors reported in the veteran's letter of December 1992 and testimony at the Travel Board hearing in January 1994. 4. The RO should contact the United States Army and Joint Services Environmental Support Group (ESG), located at 7798 Cissna Road, Springfield, Virginia, 22150 for the purpose of obtaining and associating with the veteran's claims file any documentation pertaining to the verification of stressors to which the veteran may have been exposed in connection with his Vietnam service. 5. The veteran should be afforded a VA psychiatric examination by a board of two psychiatrists in order to more accurately determine the exact nature and etiology of his claimed psychiatric disability. Each psychiatrist should individually examine the veteran. All indicated studies should be performed. The claims folder, including a copy of this REMAND, should be made available to the board of psychiatrists for their review prior to the examination. Following a review of examination findings, the board of psychiatrists should provide a diagnosis concerning any psychiatric disorder(s) found to be present and, if possible, express an opinion concerning the approximate date of the first onset of the psychiatric disorder(s). When the above-requested development is completed, the RO should again review the veteran's claims for service connection. If the veteran's claims remain denied, the veteran and his representative should be furnished an appropriate supplemental statement of the case with ample opportunity to respond. After they have had an adequate opportunity to respond, the case should be returned to the Board for further appellate review, if in order. The purpose of this REMAND is to obtain clarifying data. J. U. JOHNSON 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) (1993).