Citation Nr: 0004437 Decision Date: 02/18/00 Archive Date: 02/23/00 DOCKET NO. 97-17 383A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to service connection for bilateral hearing loss. 2. Entitlement to an increased evaluation for resection of the small intestine, currently evaluated as 40 percent disabling. 3. Entitlement to an increased evaluation for residuals of a shell fragment wound (SFW) of the right hand and arm, currently evaluated as 40 percent disabling. 4. Entitlement to an increased evaluation for an injury of the abdominal wall as a residual of SFW and surgeries, currently evaluated as 30 percent disabling. 5. Entitlement to a compensable evaluation for bilateral frozen feet. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD M. L. Wright, Counsel INTRODUCTION The veteran had active service from January 1949 to July 1952. This appeal arises from a March 1997 rating decision of the Columbia, South Carolina, Regional Office (RO). In this decision, the RO denied service connection for the veteran's bilateral hearing loss. Also denied was the veteran's claims for increased evaluations for his resection of the small intestine, residuals of a shell fragment wound (SFW) of the right hand and arm, an injury of the abdominal wall as a residual of SFW and surgeries, and bilateral frozen feet. He appealed these determinations. By rating decision of August 1997, the RO granted an increased evaluation for the veteran's abdominal wall injury to 30 percent disabling. The veteran continued his appeal. The issues of increased evaluations for resection of the small intestine, residuals of a SFW of the abdomen, and residuals of frozen feet are discussed in the remand section of this decision. FINDINGS OF FACT 1. The veteran was exposed to acoustic trauma during his combat experiences in the Korean War. 2. Although hearing loss was not shown in service, the veteran has asserted experiencing temporary total deafness in service for which he was unable receive treatment, a gradual diminishment of hearing since service, and he currently has a bilateral sensorineural hearing loss recognized as a disability for VA purposes. 3. The veteran's service-connected right arm and hand disability is characterized by well-healed scars except for a muscle hernia over the mobile wad, some loss of grip strength, some limitation of motion in the right wrist and forearm to include inability to perform ulnar and radial deviation, and slight interference with radial circulation. CONCLUSIONS OF LAW 1. With resolution of all reasonable doubt in the veteran's favor, service connection for bilateral hearing loss is warranted. 38 U.S.C.A. §§ 1110, 1154(b), 5107 (West 1991); 38 C.F.R. §§ 3.303, 3.304, 3.385 (1999). 2. An evaluation in excess of 40 percent is not warranted for the veteran's residuals of a SFW of the right hand and arm. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.10, 4.14, 4.40, 4.45, 4.59, 4.71, 4.118, Diagnostic Codes (Codes) 5206, 5207, 5208, 5209, 5210, 5211, 5212, 5213, 5214, 5215, 5307, 5308, 7803, 7804, 7805 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Factual Background The veteran was given a comprehensive physical examination in January 1949 upon his entrance into active service. He was reported to be able to hear a whispered and spoken voice at 15 feet in both ears. The veteran's separation examination was conducted in July 1952 and similar findings regarding his bilateral hearing were noted. By rating decision of August 1952, the RO awarded the veteran service connection for residuals of SFW to his right forearm. A rating of these residuals was deferred until additional medical evidence could be gathered. The veteran was afforded a U. S. Department of Veterans Affairs (VA) compensation examination in September 1952. It was noted by the examiner that the veteran made no complaints regarding his ears. In a rating decision of September 1952, the RO granted service connection for a SFW of the right forearm with muscle hernia. This disability was evaluated under the VA's Schedule for Rating Disabilities, 38 C.F.R. Part 4, Diagnostic Code (Code) 5308 as 20 percent disabling, effective from July 1952. The RO issued a rating decision in March 1953 that recharacterized the veteran's right forearm disability as a through and through SFW, depressed and tender, of the right forearm with muscle damage and hernia. This disorder was evaluated as 30 percent disabling effective from July 1952 under Code 5307. This evaluation was based on a Board decision issued in February 1953. VA treatment records dated from June 1988 to February 1990 were associated with the veteran's claims file in March 1990. These records failed to note any complaints or diagnosis for defective hearing. By rating decision of March 1990, the RO confirmed and continued the evaluations of the veteran's service-connected disabilities. In February 1997, the veteran filed a claim for an increased evaluation for residuals of a SFW of the right hand and arms. He also filed a claim for service connection for bilateral hearing loss. The veteran claimed that this hearing loss was sustained due to noise from combat to include gunfire and impacting shells. VA treatment records dated from November 1995 to October 1996 were incorporated into the claims file in March 1997. Occupational therapy records of November 1995 noted treatment of the veteran's right wrist and forearm. He complained of stiffness in his right wrist in the mornings. Range of motion in the right wrist was flexion from 0 to 30 degrees and extension from 0 to 12 degrees. At its worst, range of motion in the metacarpophalangeal (MP) joint was from 0 to 75 degrees. Approximately one month later, range of motion in the right wrist was from 0 to 30 degrees flexion and from 0 to 23 degrees extension. At its worst, range of motion in the MP joint was 0 to 85 degrees. Grip strength in the right hand was at 60 pounds and in the left at 75 pounds. A VA orthopedic examination was provided to the veteran in July 1997. It was noted that the veteran underwent surgery in October 1994 in order to repair an advanced slack wrist deformity of the right wrist that was indicative of a previous injury to his scapholunate ligament that had gone undetected in the past. This surgery consisted of scaphoid excision and ulnar column fusion of the right wrist. It was reported by the veteran that this surgery had reduced the pain in his right wrist; but had increased the stiffness, decreased range of motion, and decreased grip strength in this joint. On examination, the scars on the veteran's right forearm and wrist were well-healed. However, there was some herniation of the muscle on the wound over the mobile wad. There was no effusion in the right wrist or elbow. Range of motion in the right wrist was from 5 degrees of flexion to 10 degrees extension. The right wrist was incapable of radial or ulnar deviation. The right forearm was capable of 80 degrees of pronation and 70 degrees supination. Range of motion in the right elbow was from 0 to 135 degrees. There was full range of motion in all digits of the right hand. There was sensation to touch in the fingers of the right hand, but the veteran claimed that this was diminished when compared to the left hand. It was noted that the veteran had normal capillary refill in the right hand, but testing revealed slightly slower filling through the radial artery. Grip strength in the right hand was noted to be a 4 on a scale of 1 to 5 with grip strength in the left hand being 5 out of 5. There were early signs of Dupuytren's contracture in the right hand, but no actual contractures at the present time. The diagnoses included a history of right forearm SFW, a slack wrist deformity due to a missed scapholunate injury at sometime in the past, status post scaphoid excision and ulnar palm fusion with residual decrease in right wrist motion and right hand strength, and evidence of early Dupuytren's contracture of the right hand. In July 1997, the veteran received a VA audio examination. He reported a history of noise exposure for the three and one half years he was in the military. This included an acoustic "incident" during the veteran's combat duty in Korea when he was hit with the "back flash" of a 57 millimeter (mm) recoilless rifle. He reported post-service noise exposure to include driving long-distance trucks, outboard motors, lawnmowers, and weedeaters. Audiometry testing revealed the following results: HERTZ 500 1000 2000 3000 4000 RIGHT - 45 60 80 80 LEFT - 25 60 80 95 The average puretone threshold for the frequencies tested was 66 Hertz in the right ear and 65 Hertz in the left ear. Speech recognition was found to be 72 percent in both ears. The diagnosis was mild to profound sensorineural hearing loss on the right side in frequencies above 250 Hertz and moderate to profound sensorineural hearing loss on the left side in frequencies above 1,000 Hertz. During his hearing on appeal in January 1998, the veteran testified that he was exposed to gunfire and loud noises during his combat tour in the Korean War. He alleged that a specific incident of acoustic trauma happened during this tour when he was hit by the backblast of a 57 "caliber rifle" that he fired at the enemy. After this incident, the veteran was deaf for four days and had ringing in his ears. He asserted that his hearing later returned, but he could not go on sick call at the time because his unit was surrounded by the enemy. The veteran testified that he had a big SFW scar on his right forearm that was sustained in combat. He claimed that he had poor circulation in this arm that caused his right hand to turn white. It was also alleged by the veteran that his treating physicians had told him that his SFW had caused nerve damage in the arm. The veteran asserted that his physician's informed him that his right wrist had to be fused due to damaged cartilage that was result of a prior sprain. He testified that he did not remember ever spraining his right wrist, but felt it may have happened at the same time he received his SFW as this incident had knocked him unconscious. The veteran noted that his right arm was his dominant extremity. He claimed that he had difficulty writing and picking things up with his right hand and arm. It was alleged by the veteran that his right arm would ache and become tired. He acknowledged that there had been no swelling in his right arm since 1992. VA medical records dated from October to December 1997 were associated with the claims file in January 1998. The veteran was hospitalized from October to November 1997 for repair of an incisional ventral hernia in the lower right quadrant. Outpatient records dated in December 1997 noted follow-up to this surgery. The veteran was afforded an electromyogram (EMG) in December 1997. He complained of numbness and tingling in both hands, but worse on the right side. It was reported that the veteran was positive for a history of diabetes mellitus that was controlled with oral agents. On physical examination, the intrinsic muscles of the hands were noted to have atrophy. There was also decreased sensation in the ulnar aspect of both upper extremities with markedly positive Tinel's sign in both extremities. Limitation of motion was found in the right wrist due to surgical fusion. Motor strength was intact with some weakness, worse in the right extremity than the left. After EMG testing was complete, the impression was bilateral ulnar neuropathy with denervation, right worse then left. An outpatient record of late December 1997 noted the findings of the EMG. The impression was diabetic neuropathy. An outpatient record from late January 1998 noted that the veteran complained that his bilateral upper extremity neuropathy had become worse. He described it as a constant burning, aching pain. The veteran was provided with VA neurological and orthopedic examinations in March 1998. On the neurological examination, the veteran complained of tingling in the ulnar parts of his hands since his surgery conducted in October 1997. He also claimed that he had a tendency to drop things held in his hands due to weakness. It was also reported that the veteran had an eight- to nine-year history of diabetes. He had hearing loss that required the use of hearing aids. On examination, the veteran was found to be right-handed. There was atrophy and weakness in the right ulnar innervative hand muscles with a similar weakness noted in the same muscles of the left hand. This weakness was found to be 4 on a scale of 1 to 5. There was a positive Tinel's sign in both wrists and elbows over the ulnar nerve. Sensory testing revealed decreased pin and light touch sensation in the ulnar distribution on both sides. Coordination movements were normal. The diagnosis was bilateral ulnar neuropathy more marked on the right side. The examiner opined that this neuropathy was probably due to diabetes mellitus. The report of the VA orthopedic examination noted the veteran's complaints of numbness and tingling from his elbows to his hands. However, he claimed that his right arm was worse than his left. It was reported that these symptoms interfered with his ability to pick-up objects. On examination, the veteran was determined to be right-handed. There was positive Tinel's sign at the elbows. Significant interosseous wasting was found that was worse on the right extremity. Strength in the upper extremities was found to be normal and his reflexes were intact. The assessment was peripheral and ulnar neuropathy most likely secondary to diabetes. A supplemental statement of the case was issued to the veteran in June 1998. He was informed that his claims for service connection for hearing loss and an increased evaluation for his SFW to the right forearm had been denied. II. Analysis A. Service Connection for Bilateral Hearing Loss Service connection may be granted for disability resulting from personal injury suffered or disease contracted in the line of duty or for aggravation of a pre-existing injury suffered, or disease contracted, in the line of duty. 38 U.S.C.A. §§ 1110, 1131 (West 1991); 38 C.F.R. §§ 3.303, 3.304 (1999). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (1999). For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385 (1999). In the case of any veteran who engaged in combat with the enemy in active service with the U. S. military during a period of war, the VA shall accept as sufficient proof of service connection of any disease or injury alleged to have been incurred in or aggravated by such service satisfactory lay or other evidence of service incurrence or aggravation of such injury or disease, if consistent with the circumstances, conditions, or hardships of such service, notwithstanding the fact that there is no official record of such incurrence or aggravation in such service. Service connection of such an injury or disease may be rebutted by clear and convincing evidence to the contrary. 38 U.S.C.A. § 1154(b) (West 1991). The objective evidence indicates that the veteran was engaged in combat with the enemy during the Korean War. Given the likelihood of exposure to acoustic trauma associated with combat service, the veteran's competence to establish the occurrence of an in service injury, and the provisions of 38 U.S.C.A. § 1154(b), the Board accepts the veteran's account of experiencing acoustic trauma during these combat experiences as credible. The veteran also claims that he experienced temporary, total deafness for a brief period during combat and was unable to get medical attention. This is consistent with the circumstances of his service during the Korean War. The Board acknowledges that there is no objective evidence of hearing loss in service. His report of separation examination indicated that his hearing was the same as when he entered military service. However, this finding was based on an audible voice test that is accepted today as rather unreliable in determining actual hearing loss. Moreover, the absence of in-service evidence of hearing loss is not fatal to the claim, see Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). Evidence of a current hearing loss disability (i.e., one meeting the requirements of section 3.385, as noted above) and a medically sound basis for attributing such disability to service may serve as a basis for a grant of service connection for hearing loss. See Hensley v. Brown, 5 Vet. App. 155, 159 (1993). The veteran asserts that he has continually suffered with partial deafness since his service in the Korean War. His current hearing loss was confirmed by the VA examination of July 1997 which meets the criteria of 38 C.F.R. § 3.385. While the record contains no specific medical opinion of a nexus between the veteran's current hearing loss disability and the veteran's combat service, the audiologist did note the veteran's 3 1/2 years of combat service in the infantry and a specific incident of acoustic trauma in service involving the back flash from a 57 recoilus rifle in the history portion of the examination report. While the audiologist also noted that the veteran reported driving a truck for eight years and utilizing outboard motors, lawnmowers, and weedeaters, all of which may involve some noise exposure, the Board finds that the overall evidence suggests that it is at least as likely as not that the veteran's diminished hearing began following events during his active duty service. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Resolving all reasonable doubt in the veteran's favor, the Board finds that service connection for hearing loss is warranted. B. Increased Evaluation for Residuals of a SFW to the Right Forearm. As a preliminary matter, the Board finds that the veteran's claim is well grounded. A claim that a service-connected condition has become more severe is well grounded where the claimant asserts that a higher rating is justified due to an increase in severity. See Caffrey v. Brown, 6 Vet. App. 377, 381 (1994); Proscelle v. Derwinski, 2 Vet. App. 629, 631-632 (1992). Disability evaluations are determined by comparing a veteran's present symptomatology with criteria set forth in the VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. Part 4. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7 (1999). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3 (1999). The veteran's entire history is reviewed when making disability evaluations. See generally 38 C.F.R. 4.1 (1995); Schafrath v. Derwinski, 1 Vet. App. 589 (1995). However, the current level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The Board notes that, when evaluating musculoskeletal disabilities, the VA may, in addition to applying schedular criteria, consider granting a higher rating in cases in which functional loss due to limited or excess movement, pain, weakness, excess fatiguability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995). As noted above, the veteran's residuals of a SFW to the right forearm is currently evaluated as muscle injury assessed as 40 percent disabling under Code 5307, for severe limitation of the flexion of the fingers. As that is the highest evaluation assignable under Code 5307 (and the only applicable muscle injury code, 5308, pursuant to which limitation of extension of the fingers is evaluated, provides for a maximum evaluation of 30 percent),the Board has considered whether a higher evaluation may be assigned under any other potentially applicable diagnostic codes. Potentially applicable diagnostic criteria for evaluating orthopedic disability are set forth below (all ratings are noted for the dominant or major extremity): Code 5206. Forearm, limitation of flexion of: Flexion limited to 45 degrees; rate as 50 percent disabling. Flexion limited to 55 degrees; rate as 40 percent disabling. Code 5207. Forearm, limitation of extension of: Extension limited to 110 degrees; rate as 50 percent disabling. Extension limited to 100 degrees; rate as 40 percent disabling. Code 5208. Forearm, flexion limited to 100 degrees and extension to 45 degrees; rate as 20 percent disabling. Code 5209. Elbow, other impairment of Flail joint; rate as 60 percent disabling. Code 5210. Radius and ulna, nonunion of, with flail false joint; rate as 50 percent disabling. Code 5211. Ulna, impairment of: Nonunion in upper half, with false movement: With loss of bone substance (1 inch (2.5 centimeters) or more) and marked deformity; rate as 40 percent disabling. Code 5212. Radius, impairment of: Nonunion in lower half, with false movement: With loss of bone substance (1 inch (2.5 centimeters) or more) and marked deformity; rate as 40 percent disabling. Code 5213. Supination and pronation, impairment of: Loss of (bone fusion): The hand fixed in supination or hyperpronation; rate as 40 percent disabling. Limitation of pronation: Motion lost beyond middle of arc; rate as 30 percent disabling. Limitation of supination: To 30 degrees or less; rate as 10 percent disabling. Code 5214. Wrist, ankylosis of: Unfavorable, in any degree of palmar flexion, or with ulnar or radial deviation; rate as 50 percent disabling. Any other position, except favorable; rate as 40 percent disabling. Favorable in 20 degrees to 30 degrees dorsiflexion; rate as 30 percent disabling. * Note: Extremely unfavorable ankylosis will be rated as loss of use of hands under Code 5125. Code 5215. Wrist, limitation of motion of: Dorsiflexion less than 15 degrees; rate as 10 percent disabling. Palmar flexion limited in line with forearm; rate as 10 percent disabling. 38 C.F.R. § 4.71 (1999). A review of the orthopedic codes noted above indicates that evaluation of the disability on the basis of limitation of motion under Codes 5213 or 5215 for the wrist and forearm would not warrant an evaluation in excess of 40 percent. In order for the veteran to receive an evaluation in excess of 40 percent, he would have to have significant limitation of motion in his right elbow joint (Codes 5206, 5207), a flail joint in the right elbow (Code 5209), nonunion of the radius or ulna bones (Codes 5210, 5211, 5212), or ankylosis of the wrist in an unfavorable position (Code 5214), none of which is shown. The veteran has not claimed, nor does the objective evidence reflect, any service-connected disability affecting movement of his right elbow. There is no objective evidence of, or of disability comparable to, a flail joint or nonunion of the radius or ulna. While his right wrist has been fused to the point that radial and ulnar deviation is no longer possible, the objective evidence indicates that the veteran's right wrist is still capable of flexion and extension and his right forearm can pronate and supinate. Thus, ankylosis is not medically shown, and, even considering the veteran's complaints of flare-ups of pain and fatigue, there is no indication that he experiences right forearm and hand disability that is comparable to unfavorable ankylosis. Thus, a higher evaluation is not possible under the noted criteria, even when subjective complaints of pain and fatigue are considered. The veteran's neurological complaints concerning his right upper extremity have been determined by two different examiners in March 1998 to be the result of the veteran's diabetes mellitus, a nonservice-connected disability. This finding is supported by the EMG of December 1997 and the veteran's own complaints which noted neuropathy in all of his extremities, not just his right forearm and hand. Thus, this symptomatology cannot be considered in evaluating the service-connected disorder. Moreover, while a symptomatic scar could warrant assignment of an additional 10 percent evaluation (Codes 7803, 7804, and 7805) in this case, the veteran's scars, themselves, are shown to be well healed and not symptomatic. In any event, any symptoms that possibly could be associated with scars, such as pain deformity, and limited motion, have already been taken into consideration in assignment of the current 40 percent evaluation. As indicated above, recent evidence indicates that the veteran's residuals of a SFW to the right forearm include well-healed scars except for a muscle hernia over the mobile wad, some loss of grip strength, some limitation of motion in the right wrist and forearm to include inability to perform ulnar and radial deviation, and slight interference with radial circulation. He subjectively complains of pain. The Board finds that the current 40 percent evaluation under Code 5307 adequately compensates the veteran for his overall disability picture, and that there simply is no lay or medical evidence that would establish symptomatology of his SFW to the right arm and hand that would warrant the grant of an evaluation in excess of 40 percent under any of the applicable diagnostic codes. Based on the foregoing, the Board must conclude that an evaluation in excess of 40 percent for the residuals of his SFW to the right arm and hand is not warranted. In reaching this conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the veteran's claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C.A. § 5107(b) (West 1991); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1991). ORDER Service connection for bilateral hearing loss is granted. An evaluation in excess of 40 percent for residuals of a SFW of the right hand and arm is denied. REMAND The last compensation examination that evaluated that residuals of the SFW to the veteran's abdomen and resection of the small intestine was conducted in July 1997. Since that examination, the veteran has undergone surgery in October 1997 to repair a ventral hernia. This surgical procedure resulted in complications from infection and further surgery was required. The post-hospitalization records indicate the veteran's continued complaints of abdominal pain. In January 1998, the outpatient examiner noted that the veteran's abdominal problems were of a complicated nature. The last VA orthopedic examination in March 1998 failed to discussed the residuals of the veteran's SFW to the abdomen. Under the circumstances, it appears that the veteran's abdominal problems have changed in nature and degree since his last VA compensation examination. Thus, in order to provide an accurate picture of current symptomatology, new VA orthopedic and gastrointestinal examinations are required. As regards the veteran's claim for a compensable evaluation for frostbite, the Board notes that, effective January 12, 1998, the rating criteria for cold weather injuries at Code 7122 were changed. When a law or regulations change during the pendency of a veteran's appeal, the version most favorable to the veteran applies, absent congressional or Secretarial intent to the contrary. Karnas v. Derwinski, 1 Vet. App. 308, 312-13 (1991). To date, the RO has not had the opportunity of adjudicating the veteran's claim for an increased rating of his pulmonary disorder under the recently finalized regulatory changes. Further action, to include the RO's adjudication of the veteran's claim under the revised criteria, is need. In the event such claim continued to be denied, notice to the veteran of the most recent rating criteria is also required so that he may respond with appropriate argument in support of his claim for an increased rating. The Board also notes that VA examinations of the veteran's feet in recent years has failed to include radiological studies or examiners' opinions on the existence of changes to the bones of his feet as a result of his frostbite from the Korean War. Therefore, a new VA examination will be required on remand. Under these circumstances, the Board finds that further development is required, and the case is hereby REMANDED to the RO for the following action: 1. The RO should obtain and associate with the claims file all pertinent outstanding medical records from the VA Medical Center in Charleston, South Carolina, and any other source or facility identified by the veteran, dated from February 1998 to the present. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact should clearly be documented in the claims file. 2. Following completion of the above development, the veteran should be afforded VA orthopedic and gastrointestinal examinations. The purpose of these examinations is to determine the full nature and extent of the veteran's service-connected residuals of a SFW to the abdomen, resection of the small intestine, and residuals of frostbite of the feet. All necessary tests, studies, and consultations (to include a neurological consult) should be accomplished, and all clinical findings should be set forth in detail. In regard to the veteran's feet, the orthopedic examiner should determine whether radiological studies are required to determine if any osteoporosis, subarticular punched out lesion, and/or osteoarthritis exists in the veteran's feet as a residual of his service- connected cold weather injury. If the examiner determines that radiological studies are not required, he or she should provide a reasons and bases for this decision. The orthopedic examiner should specifically address the following in his or her report: a. Please describe in detail for the record the extent of the muscle damage and any residuals caused by the veteran's SFW to his abdomen. In your best medical judgment, would this muscle damage be characterized as slight, moderate, moderately severe, or severe? b. Please describe in detail, to include measurements, the veteran's service-connected scar(s) over his abdomen. Are these scars painful on objective examination? Is there any evidence of hernia or other defects? c. Does the veteran's feet evidence tissue loss, nail abnormalities, color changes, hyperhidrosis, osteoporosis, subarticular punched out lesion, and/or osteoarthritis as a result of his service-connected cold weather injury? The gastrointestinal examiner should provide answers to the following questions in his or her report: Please describe in detail any interference with absorption and nutrition and/or impairment with the veteran's health caused by his service-connected resection of the small intestine. Each examiner must include the complete rationale for all conclusions reached in a typewritten report. Each report should be associated with the claims file. 3. Thereafter, the RO must review the claims file to ensure that all of the foregoing development actions have been conducted and completed in full. If any development is not undertaken, or is incomplete, including if a requested examination does not include all opinion requested, appropriate corrective action is to be implemented. 4. After completion of the foregoing requested development, and after completion of any other development deemed warranted by the record, the RO should adjudicate the veteran's claim for an increased evaluations for his service- connected disabilities. Such adjudication should be accomplished on the basis of all pertinent evidence of record, and all pertinent legal authority, specifically to include that cited to herein. In adjudicating the veteran's claim for a compensable evaluation for residuals of frostbite, the RO should consider the former and the revised applicable schedular criteria, and apply the more favorable result (if any). The RO should provide adequate reasons and bases for its decision, citing to all governing legal authority and precedent, and addressing all issues and concerns that are noted in this REMAND. 5. If any determination remains adverse to the veteran, he and his representative should be furnished with an appropriate SSOC (to include citation to all additional laws and regulations considered) and given a reasonable opportunity to respond before the case is returned to the Board for further appellate consideration. The purpose of this REMAND is to afford due process and to accomplish additional development and adjudication; it is not the Board's intent to imply whether the benefits sought should be granted or denied. The veteran need take no action until otherwise notified, but he may furnish additional evidence and/or argument during the appropriate time period. See Kutscherousky v. West, 12 Vet. App. 369 (1999); Colon v. Brown, 9 Vet. App. 104, 108 (1996); Booth v. Brown, 8 Vet. App. 109 (1995); Quarles v. Derwinski, 3 Vet. App. 129, 141 (1992). This REMAND must be afforded expeditious treatment by the RO. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims (known as the United States Court of Veterans Appeals prior to March 1, 1999) for additional development or other appropriate action must be handled in an expeditious manner. See The Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 302, 108 Stat. 4645, 4658 (1994), 38 U.S.C.A. § 5101 (West Supp. 1998) (Historical and Statutory Notes). In addition, VBA's Adjudication Procedure Manual, M21-1, Part IV, directs the ROs to provide expeditious handling of all cases that have been remanded by the Board and the Court. See M21-1, Part IV, paras. 8.44- 8.45 and 38.02-38.03. JACQUELINE E. MONROE Member, Board of Veterans' Appeals