BVA9502562 DOCKET NO. 92-06 434 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Seattle, Washington THE ISSUE Entitlement to service connection for residuals of rheumatic fever, to include rheumatic heart disease, a heart murmur, and inflammatory joint disease. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESSES AT HEARING ON APPEAL Appellant and his spouse ATTORNEY FOR THE BOARD P. J. McCarty, Associate Counsel INTRODUCTION The veteran served on active duty from January 1944 to May 1945. This matter comes before the Board of Veterans' Affairs (Board) on appeal from a March 1991 decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Seattle, Washington. In September 1993, the Board remanded the veteran's case for further development. REMAND Essentially, the veteran contends that service connection is warranted for residuals of rheumatic fever, to include rheumatic heart disease and a heart murmur, and that service connection is warranted for inflammatory joint disease which initially manifested in service. Historically, the veteran was diagnosed as having active rheumatic fever and possible rheumatic heart disease in service. Service medical records reveal that the veteran reported having recurring joint pain in his heels, buttocks, ankles, knees, and his right hip. He stated that at the age of nine, he had "inflammatory rheumatism" and that at that time his right knee and right wrist were swollen. A November 1944 hospital discharge summary reveals that he had swelling in his right ankle and left knee, and that he was diagnosed as having rheumatic fever and a heart murmur. In May 1945, the veteran was separated from service because of ill health. At that time, he was diagnosed as having rheumatic fever with reactivity, history of two prior hospitalizations. A September 1990 VA examination report revealed no clinical evidence of inflammatory joint disease in any joints despite the veteran's complaints of recurrent ligamentous disease of the shoulders, hands, wrists, knees, ankles, hips, and neck. The examiner also found that although the veteran was told he had a heart murmur in service, he had no significant cardiac complaint at the time of examination. In contrast, x-rays dated in October 1990 revealed that the veteran had degenerative joint disease in the right hip, and regional type osteoarthritis involving the heads of the metacarpals and the bases of the phalanges; these findings were noted as compatible with rheumatoid arthritis, but not specific for the same. The interphalangeal joints of the fingers showed no symmetrical thinning of the joints to suggest rheumatoid disease was present. Some degenerative arthritic changes were seen in the distal interphalangeal joints of both hands, and at the base of the first metacarpal with the tapezium. X-rays of the heart showed no evidence of cardiomegaly or active pulmonary disease. Progress notes from the Wenatchee Valley Clinic, dated in July 1991, show that the veteran complained of migratory oligoarthritis, predominantly in the knee, and sometimes in the ankle, shoulder, hip, neck, and wrist. At the time of the examination he had discomfort in his left wrist, both shoulders, and in the region of the Achilles tendons. The examiner diagnosed HLA-B27 arthropathy. He found that the veteran's long history of intermittent oligoarthritis was more consistent with that diagnosis than with rheumatoid arthritis, gout, or pseudogout. A November 1991 VA examination report shows that the veteran complained of joint and musculoskeletal pain in multiple joints since his separation from service. He reported problems with his knees, ankles, wrists, shoulders, hips, as well as with tendons in his groin and his Achilles tendons. The examiner noted that there were no remarkable joint findings, although the veteran reported discomfort in several of the joints during range of motion testing and tenderness in various tendon groups. The examiner found that the etiology of the veteran's discomfort was not clear. X-rays revealed degenerative changes in the right hip, in the glenohumeral joints, in the left radiocarpal joint, in the right first metacarpal joint, degenerative changes in both sacroiliac joints and symphysis pubis, and probable degenerative changes in the left hip. Because there are conflicting diagnoses in evidence regarding the etiology of the veteran's arthritis, the Board finds that further development and more current data would be helpful to the Board's evaluation of the issue of service connection for inflammatory joint disease. VA has a duty to assist the veteran in the development of facts pertinent to a well-grounded claim. 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. § 2.103(a)(1993). The United States Court of Veterans Appeals has held that the duty to assist the veteran includes the duty to obtain examinations when indicated, and the duty to obtain pertinent medical records. Hyder v. Derwinski, 1 Vet.App. 221 (1991); Green v. Derwinski, 1 Vet.App. 121 (1991); Littke v. Derwinski, 1 Vet.App. 90 (1990). Accordingly, the Board concludes that further development, as specified below, is necessary. The case is therefore REMANDED to the RO for the following actions: 1. The RO should contact the veteran and request that he identify the names, addresses, and approximate dates of treatment for all VA and non-VA health care providers who have treated him for residuals of rheumatic fever to include arthritis and/or inflammation of the joints and heart disease. With any necessary authorization, the RO should attempt to obtain all pertinent treatment reports identified by the veteran which have not been previously secured. 2. The veteran should be afforded a VA examination by a board certified rheumatologist, if available, to determine the nature and extent of the veteran's arthritis. The examiner should also review the claims folder and offer an opinion as to whether it is at least as likely as not that the veteran's current arthritis is related to rheumatic fever that he had in service. The rationale for all opinions expressed should be provided. All indicated studies should be performed. The claims folder must be made available to the examiner for review prior to the examination. 3. The veteran should be provided a VA examination by a board certified cardiologist, if available, for the purpose of determining whether the veteran has any currently identified heart disease, and, if so, whether it is at least as likely as not whether such heart disease can be associated with the rheumatic fever noted in service. All indicated studies should be performed and the claims folder must be made available to the examiner for review prior to the examination. 4. Then, the RO should readjudicate the issue on appeal. If the benefit sought on appeal are not granted to the veteran's satisfaction, or if a timely notice of disagreement is received with respect to any other matter, the RO should issue a Supplemental Statement of the Case for all issues in appellate status, and the veteran and his representative provided an opportunity to respond. Thereafter, the case should be returned to the Board for further consideration, if otherwise in order. By this REMAND, the Board intimates no opinion as to any final outcome warranted. No action is required of the veteran until he is otherwise notified by the RO. ROBERT E. SULLIVAN 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 (CONTINUED ON NEXT PAGE) 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. The above 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).