BVA9505389 DOCKET NO. 93-12 358 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to an increased rating for a total thyroidectomy, evaluated as 10 percent disabling. 2. Entitlement to an increased rating for hypertension, evaluated as 10 percent disabling. 3. Entitlement to an increased (compensable) rating for reflux esophagitis. 4. Entitlement to an increased (compensable) rating for status post Achilles' tendon sprain. 5. Entitlement to service connection for an organic heart disorder. ATTORNEY FOR THE BOARD Alice A. Booher, Counsel INTRODUCTION A DD 214 is in the file showing that the veteran had service from January 1977 to March 1992, with 5 years, 1 month and 13 days prior unverified service. In February 1993, a rating action by the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama, indicated that service connection was being granted for total thyroidectomy, hypertension, history of reflux esophagitis, and status post Achilles tendon sprain; disability ratings were assigned at 10 percent, 10 percent, zero and zero percent, respectively. The rating action also denied service connection for various others disabilities including a heart disorder. It is from this rating action that the appeal is taken. REMAND Although active service from 1971 to 1977 is uncertified, some service medical records from that period are in the file. A copy of a letter from the RO to the veteran, dated February 19, 1993, is in the file, reflecting that service connection had been established for total thyroidectomy (rated at 10 percent) and hypertension (rated at 10 percent), as well as reflux esophagitis and Achilles tendon sprain, (each rated as zero percent disabling), for a combined 20 percent evaluation; and that service connection had been denied for various conditions including a heart disorder. A copy of a letter from the RO to the veteran, dated February 23, 1993, is also in the file, reflecting that service connection had been granted for "stenosis of the stomach (rated 10 percent), hypertension (rated 10 percent), a "condition of the upper digestive system" and "foot injury-right", (each evaluated as zero percent disabling), for a combined evaluation of 20 percent. In his VA Form 21-4138 of March 1993, in part, and in his VA Form 9, in May 1993, the veteran expressed his confusion over the RO's defining of the disorders for which he had been granted service connection and the correct combined rating. Twice, he requested clarification. For reasons unknown, the RO did not respond to either inquiry. A Subsequent Statement of the Case addressed the issues identified in the February 19, 1993, letter. The veteran, in his VA Form 9, also noted that while he had had surgery for hypothyroidism, the RO's adjudication of his claim and associated disability rating were designated on the basis of hyperthyroidism, for which distinct and different criteria are applicable. Service medical records indicate that during service, the veteran underwent a thyroidectomy for cold nodules with alternating diagnoses of hyperthyroidism and hypothyroidism. Service medical records show that on several occasions, the veteran complained of chest pain. He was reported to have an irregular pulse and pressure in his chest in November 1985. In 1986, he was also reportedly seen for myocarditis (at a Germany Hospital, records from which are not in the file) and elevation of liver enzymes. It was also noted that while his hypertension was under relatively good control with medication, he had a history of extra heart beats. It is unclear to what these were attributed. A number of electrocardiograms (ECG)'s performed in service are in the file. In service, he underwent specialized cardiac testing including a treadmill test at least in 1986 and 1989. Findings were reportedly normal; it was suggested that there was a low percentage chance of his having significant arteriosclerotic cardiovascular disease. The veteran has also pointed out that in addition to hypertension, on the VA examination in 1993, an ECG was identified as borderline abnormal (normal sinus rhythm with occasional premature ventricular complexes, nonspecific intraventricular condition delay) and mild cardiomegaly was shown on chest X-ray; yet, service connection was denied for a heart disorder on the basis that one had not been shown on the last examination. A copy of an undated letter from the RO to the veteran is in the file identifying those two findings as abnormal and recommending that he needed to discuss them with his doctor at his earliest convenience. The report of the January 1993 VA examination shows few clinical findings but a number of diagnostic conclusions. No clinical correlation was made concerning the service and post-service clinical findings, hypertension and the possibility of organic heart disease, nor were the findings specifically indicative of the veteran's service-connected disabilities discussed in detail. The examiner noted a history of abnormal liver functions studies and said that tests would redocument the findings; laboratory test results in the file show elevation SGOT of 187 U/L (normal range being 0-47), but there was no clinical correlation of these and any other findings, and no other further evaluative tests, including thyroid studies, were undertaken. On the basis of the evidence of record, the Board finds that additional development is required. Accordingly, the case is REMANDED for the following actions: 1. The service department should be requested to certify all of the veteran's periods of active duty, including from 1971 to 1977, and to obtain all additional service medical records. An attempt should be made to obtain records for the veteran's care at a German Hospital for myocarditis in 1986. 2. The veteran should be requested to provide any evidence that may be of benefit to his claim with regard to disabilities identified as service-connected on both RO letters in February 1993, as well as any organic heart or liver symptoms, including complete copies of records for all VA, service department, private facility or physician post-service care for any of these disorders. The RO should assist the veteran in acquiring these records as required, and the records should then be attached to the claims folder. 3. The veteran should be examined by VA specialists in cardiology, endocrinology, gastroenterology/hepatology, and orthopedics, who have not examined him, on a fee basis if necessary, to determine the exact nature and extent of all current cardiovascular, endocrine, liver, gastrointestinal and tendonitis disorders. The examinations must be conducted in accordance with the VA Physician's Guide for Rating Disability Evaluations. All necessary laboratory and other tests including chest X-rays, cardiovascular studies, serial thyroid and liver function tests must be conducted, and findings must be specifically correlated with the other clinical evidence of record. The claims folder, a copy of this REMAND, and all of the evidence including that obtained pursuant to this remand must be made available to the examiners prior to their evaluation of the case. The cardiologist should provide an opinion as to whether in addition to hypertension, the veteran currently demonstrates an organic heart disorder, and if so, the nature thereof. The endocrinologist should opine as to the nature of all residuals of thyroid problems, and should coordinate all pertinent clinical findings with the gastroenterologist as to the nature, extent and etiology of all current thyroid and liver dysfunctions, if any. 4. Thereafter, the case should be reviewed by the RO on all pertinent issues, and if the decision remains unsatisfactory, a supplemental statement of the case should be prepared to include all evidence and pertinent law and regulations. The RO must clarify those disorders for which service connection has and has not been granted, and in the former instance, the rationale for the ratings assigned. The veteran should then be afforded a reasonable opportunity to respond. The case should then be returned to the Board for further appellate review. The veteran need do nothing further until so notified. RENÉE M. PELLETIER 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).