BVA9500141 DOCKET NO. 93-05 831 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for a chronic sinus disorder. 2. Entitlement to service connection for tinnitus. 3. Whether new and material evidence has been submitted to reopen a claim of service connection for bilateral defective hearing. 4. Whether new and material evidence has been submitted to reopen a claim of service connection for post traumatic stress disorder (PTSD). 5. Entitlement to an increased (compensable) rating for the residuals of an injury of the right wrist. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant INTRODUCTION The veteran had verified active military service from July 1965 to July 1967, from August to October 1971, and from November 1990 to March 1991. The record suggests other active service, and over 16 years of inactive service. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) of St. Petersburg, Florida. REMAND The VA has a duty to assist a veteran in developing facts pertinent to a potentially well grounded claim. 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. §§ 3.103, 3.159 (1993). That duty includes obtaining medical records and medical examinations where indicated by the facts and circumstances of an individual case. See Murphy v. Derwinski, 1 Vet.App. 78 (1990); Littke v. Derwinski, 1 Vet.App. 90 (1990). As noted above, the veteran has several periods of active service that have been verified. The DD Form 214 on file, following his participation in Operation Desert Storm, notes a total of 4 years and 8 days of "prior active service." This is more active service than has been currently verified. The veteran has testified that he was in Germany in the mid-1980's and it is possible that this constitutes part of the missing active service. Verification of all service is needed in evaluation of the claims for service connection. This same DD Form 214 lists over 16 years of "prior inactive service." A determination should be made if there were periods of reserve duty training, active or inactive during those 16 years. The veteran has suggested that he has done some flying as part of his reserve duty. It does not appear that the veteran's reserve unit was specifically contacted for service medical records. It is possible that there are annual physical examinations in those records, or other medical records which would be probative as to the issues before us. Some records from an Air Force Base where the veteran gets some treatment have been obtained, including some records for when the veteran was stationed in Germany, but it is not clear that these constitute all reserve unit medical records that may be available records. The audiometric results recorded on the entrance and separation examinations from the first period of service show some changes. The separation examination from that service and the "ISO" readings recorded at entry into the second period of service in 1971 are very similar. An annual reserve examination on file shows a decrease in hearing acuity. Hearing loss was noted on the recent VA examination. In view of the fact additional development is otherwise needed, an opinion will be requested as to whether there was evidence of hearing loss in the first period of service, and whether current hearing impairment is consistent with any in-service loss that might be found. It is noted that the veteran is a County truck driver and has been warned about acoustic trauma on the job. The veteran is seeking service connection for PTSD. His reported stressors are from the first period of service in the Navy. Life threatening stressors have not been specifically confirmed or otherwise verified.. There have been traumatic events in the veteran's life since service, including the sudden death of his father as explained in a letter in the record. When examined in early 1986, PTSD was not found. When examined in December 1991, it was noted historically that the veteran was "suffering" from PTSD. Traumatic stress disorder, delayed, was diagnosed, but the basis of this diagnosis is not clear from the record. Life threatening stressors are not described in the examination findings. It is not clear that any specific psychiatric testing was conducted, and it is not clear whether any PTSD is related to service, or to post-service events. Additional study is indicated. The record reveals that the veteran has been going to a Vet Center for treatment since 1985. The actual treatment records are not on file, but should be requested. It is not clear whether testing may have been done at that facility, but if so, those records should be obtained. In view of the foregoing, this case is REMANDED for the following actions: 1. The RO should, with the veteran's assistance as indicated, obtain verification of the dates of all military service, to include active service, active duty for training, and inactive duty for training. Thereafter, a request should be made for all service medical records for the reserve duty to include any annual physical examinations that were conducted. 2. The RO should obtain copies of all treatment records pertaining to this veteran from the Vet Center where he has been receiving treatment since 1985. These records should include copies of any tests done at the center to arrive at the diagnosis of the veteran's psychiatric disorder. Any records obtained should be associated with the claims folder. 3. The RO should forward all the veteran's records to an audiologist for review. The audiologist, after reviewing the veteran's records should enter an opinion as to (1) whether any defective hearing was deomonstrated in the first period of service; (2) if so whether it appeared to be chronic; and (3) to offer an opinion as to the etiology of any defective hearing found on the most recent examination, having the knowledge that the veteran has been exposed to aircraft noise in service and knowing that there has been some concern about the veteran's acoustic trauma at his employment. 4. The veteran should be scheduled for a comprehensive psychiatric examination by a Board of 2 psychiatrists who have not previously examined the veteran. All indicated tests should be performed and all clinical findings should be reported in detail. The claims folder should be made available to the examiners for review prior to the examination. Specific testing should be undertaken to arrive at a psychiatric diagnosis. If PTSD is diagnosed the examiners should indicate whether they attribute it to service or whether they attribute it to other than service causes. The stressors found sufficiently threatening to support the diagnosis should be specifically delineated by the examiners. When the aforementioned development has been accomplished the case should be reviewed by the RO. In the event the benefits sought are not granted, the veteran and his representative should be provided with a supplemental statement of the case and afforded a reasonable opportunity to respond thereto. Thereafter, the case should be returned to the Board for further appellate consideration. No action is required of the veteran until he is notified. MICHAEL D. LYON 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).