BVA9504006 DOCKET NO. 93-05 748 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUE Entitlement to an increased (compensable) rating for the veteran's service-connected residuals, right pneumothorax. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD P. B. Werdal, Associate Counsel INTRODUCTION The veteran served on active duty from September 1964 to September 1967. This matter came before the Board of Veterans' Appeals (Board) of the Department of Veterans Affairs (VA) on appeal from a decision dated June 22, 1992, from the St. Louis, Missouri, Regional Office (RO). The notice of disagreement was received in July 1992. The statement of the case was sent to the veteran in November 1992. The substantive appeal was received in December 1992. The Board notes that the veteran's initial claim did not identify whether he sustained a left pneumothorax or a right pneumothorax in service. It was surmised that it was a left pneumothorax, and service connection was granted for that disability. However, a private medical report dated in 1967 established that the pneumothorax occurred on the right side, so in a February 1993 rating decision the disability was correctly characterized as service connection for residuals, right pneumothorax. The Board points out that the veteran raised claims of entitlement to service connection for a right shoulder disability sustained in service secondary to treatment of his pneumothorax, and for service connection for pneumonia. Those claims were denied in a decision dated February 18, 1993. The notice of disagreement regarding that decision was received in March 1993. To date a statement of the case addressing those claims has not been prepared and provided to the veteran. The Board refers those claims to the RO for appropriate action. REMAND A VA examination for compensation purposes was performed in September 1992. The form provided for the examiner to use is entitled "Full Exam Worksheet for NON-TUBERCULOUS DISEASES AND INJURIES OF THE RESPIRATORY SYSTEM," and contains a place for specific evaluation information wherein the examiner is asked to state whether the disease, apparently a reference to an otherwise unidentified non-tuberculous disease and injury of the respiratory system, is in remission or demonstrably active. The examiner's response was that it was demonstrably active, and he identified symptoms. The examiner's diagnoses were dyspnea- multifactorial; obesity; rule out congestive heart failure; questionable stable angina pectoris; restrictive ventilatory duct, mild; and degenerative joint disease. However, it is not clear from the examiner's report that he meant the residuals of pneumothorax were demonstrably active, and that chest pain and pedal edema were attributed to the residuals of pneumothorax, or if some other non-tuberculous disease and injury of the respiratory system was demonstrably active and the symptoms identified were attributable to the other diagnoses noted at the end of the report. In assessing the veteran's percentage rating, it is important to identify the specific manifestations which are attributable to the disability for which service connection has been granted, that is, residuals of a right pneumothorax. For this reason, a new examination should be performed so information can be obtained from which VA can ascertain which symptoms the veteran currently suffers due to his service- connected right pneumothorax. Furthermore, the Board notes that the statement of the case reports that the veteran smokes, but it does not take into account the veteran's statements to the contrary. In that regard, the veteran pointed out in his substantive appeal that he smoked until 1967, then stopped pursuant to his doctor's orders. Also, according to the report of the PFT, the veteran stopped smoking 25 years previously. The Board observes that a medical record of a consultation on July 6, 1983, reports that the veteran is a "known smoker." However, that is apparently a typographical error: it should be "non-smoker". There is no reference in the other medical evidence to contradict the veteran's claim that he stopped smoking in 1967, and the statement of the case issued following the action directed on remand should clarify that fact. VA has a duty to assist in the nonadversarial process of claims adjudication. 38 U.S.C.A. § 5107 (West 1991); 38 C.F.R. § 3.103(a) (1994). That duty to assist includes providing the veteran with the opportunity for an adequate VA examination when necessary, and obtaining copies of medical records. Hyder v. Derwinski, 1 Vet.App. 221 (1991); Littke v. Derwinski, 1 Vet.App. 90 (1990). Under the circumstances of this case, additional development is necessary. Accordingly, this matter is REMANDED for the following action: 1. The RO should contact the veteran and his representative and obtain the names and addresses of physicians who have treated the veteran, and with their assistance request copies of records reflecting medical treatment administered for symptoms of his service-connected disability since 1991. Any records obtained should be associated with the veteran's claims folder. 2. The veteran should be afforded an examination to identify the symptoms and manifestations, if any, of his service- connected residuals of right pneumothorax. All necessary testing should be performed. The examiner should be provided with the veteran's medical records, including the documents obtained, if any, in response to paragraph one above, prior to examining him. All findings must be reported legibly, in detail, and should include information regarding the frequency, severity and etiology of episodes, if any, of dyspnea and chest pain. Furthermore, the examiner should specifically identify what symptoms of residuals of right pneumothorax, if any, the veteran suffers from, and provide detailed information regarding their frequency and severity. Following completion of that action, if the matter is not resolved to the appellant's satisfaction, he and his representative should be provided with a supplemental statement of the case that summarizes the relevant evidence including the correct information regarding whether the veteran currently smokes, and contains a citation to and discussion of the applicable laws and regulations, the reasons and bases for the decision, and a discussion of the application of the laws and regulations to the evidence. The purpose of this REMAND is to assist the veteran in developing his claim. No action is required of him until further notice. The Board expresses no opinion, either factual or legal, as to the ultimate determination warranted in this case pending completion of the requested action. G.H. SHUFELT 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).