BVA9505175 DOCKET NO. 93-11 488 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Boise, Idaho THE ISSUES 1. Entitlement to an increased rating for residuals of a shell fragment wound of the right shoulder, currently evaluated as 10 percent disabling. 2. Entitlement to an increased rating for residuals of a shell fragment wound to the back of the head, currently evaluated as 10 percent disabling. 3. Entitlement to an increased rating for post-traumatic stress disorder, currently evaluated as 10 percent disabling. 4. Entitlement to a total rating based on individual unemployability due to service-connected disability. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Milo H. Hawley, Counsel REMAND The veteran had active service from February 1968 to March 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from February and September 1991 decisions by the Department of Veterans Affairs (VA) Regional Office in Boise, Idaho (RO). It is contended that the veteran's residuals of shell fragment wounds to the right shoulder and the back of his head and his post-traumatic stress disorder are more disabling than currently evaluated. It is asserted that the veteran experiences headaches, shoulder pain, inability to do overhead work because of his shoulder, and nightmares, flashbacks, and social isolation. It is also noted that the veteran has been awarded Social Security benefits on the basis of disability. The report of a January 1991 VA psychiatric examination diagnoses both post-traumatic stress disorder and schizophrenia. This is the initial diagnosis of post-traumatic stress disorder, and was the basis for the award of service connection for this disability. The report of a January 1991 VA examination indicates that the veteran has excellent motion and strength of the right shoulder, but it does not indicate range of motion of the right shoulder in degrees. A July 1991 letter from James M. Retmier, M.D., a private physician, states that the veteran has pain and weakness in his right upper extremity due to residuals of the shell fragment wound to his right shoulder. It indicates that the veteran is restricted in any type of occupation which would require him to work with his arm held over his shoulder level. It further indicates that the veteran would be restricted to lifting no more than 40 to 50 pounds. A July 1992 VA outpatient treatment record reflects that the veteran complained of chronic headaches. The impression was headaches which were questionably related to old scalp trauma from shrapnel wound. The appellants accredited representative has also raised issues of entitlement to service connection for schizophrenia as well as service connection for a seizure disorder secondary to the shell fragment wound to the head. On the basis of the above record, the Board believes that additional development is required. The appeal is REMANDED to the RO for the following: 1. The RO should contact the Social Security Administration and request copies of all medical and administrative records relating to its finding that the veteran is disabled. 2. The RO should contact the veteran and inquire as to where he has been receiving health care from July 1992 until the present. The RO should contact the health care provider(s) identified, including Dr. Retmier, and request copies of all records relating to treatment of the veteran's right shoulder, head, and psychiatric disability from July 1992 until the present. 3. The RO should schedule the veteran for VA psychiatric, orthopedic, and neurology examinations, to determine the nature and extent of his post-traumatic stress disorder, and residuals of shell fragment wounds to the right shoulder and back of head. The examinations must be conducted in accordance with the VA Physician's Guide for Disability Evaluation Examinations. All indicated tests, including appropriate psychological studies with applicable subscales, must be conducted. Range of motion where pertinent should be set forth in degrees. The claims file must be made available to and reviewed by the examiners prior to the requested examinations. The psychiatric examiner must assign a Global Assessment of Functioning Score consistent with the American Psychiatric Association's DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS. (3d ed. Rev. 1987), and explain what the assigned score represents. The degree of psychiatric disability which is attributable to post-traumatic stress disorder and the degree of psychiatric disability which is attributable to a schizophrenic disorder should be separately identified, to the extent feasible, as was done in the report of the January 1991 VA psychiatric examination. Additionally, the psychiatric examiner is requested to advance an opinion with regard to the etiology of schizophrenia. The examining neurologist is requested to furnish an opinion as to whether a seizure disorder, if present, is etiologically related to the service connected shrapnel wound to the head. All examiners are requested to comment on the extent to which any service connected disability impairs to the veteran's ability to work. A complete rationale for any opinion expressed must be provided. 4. Following completion of the foregoing, the RO must review the claims folder and ensure that all of the foregoing development actions have been conducted and completed in full. Such development includes adjudicating the issues of service connection for schizophrenia and a seizure disorder. If any development is incomplete, including if the requested examinations do not include all test reports, special studies, or opinions requested, appropriate corrective action is to be implemented. Following completion of the above, the RO should review the evidence and readjudicate the veteran's claims. Thereafter, the veteran and his representative should be furnished with a supplemental statement of the case and be given the appropriate opportunity to respond thereto. Thereafter, the claims file, including any evidence obtained, should be returned to this Board for further appellate review, if in order. No action by the veteran is required until he receives further notice. The purpose of this REMAND is to procure clarifying data. The Board intimates no opinion, either legal or factual, as to the ultimate disposition of this appeal. JEFF MARTIN 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).