BVA9507790 DOCKET NO. 93-16 264 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in St. Paul, Minnesota THE ISSUES 1. Entitlement to service connection for post traumatic stress disorder (PTSD). 2. Entitlement to service connection for tinnitus. 3. Entitlement to a permanent and total disability evaluation for pension purposes. REPRESENTATION Appellant represented by: AMVETS ATTORNEY FOR THE BOARD L. M. Barnard, Counsel REMAND The veteran served on active duty from June 1969 to May 1971. This appeal arises from a February 1992 rating decision of the St. Paul, Minnesota, Department of Veterans Affairs (VA), Regional Office (RO), which denied entitlement to service connection for PTSD and tinnitus. A rating action issued in July 1992 denied entitlement to a permanent and total disability evaluation for pension purposes. The veteran contends, in essence, that he suffers from PTSD and tinnitus as a direct result of his period of service in Vietnam. Therefore, he believes that service connection should be granted. Furthermore, he also alleges that he is unable to engage in substantially gainful employment because of his various disabilities. Therefore, he also believes that entitlement to a pension should be granted as well. VA has a duty to assist the veteran in the development of all facts pertinent to his claims. 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. § 3.103(a) (1994). This includes the duty to obtain VA examinations which provide an adequate basis upon which to determine entitlement to the benefits sought, as well as the duty to obtain all relevant treatment records. Littke v. Derwinski, 1 Vet.App. 90 (1991). Examinations by specialists are recommended in those cases which present a complicated disability picture. Hyder v. Derwinski, 1 Vet.App. 221 (1991). In regard to the veteran's claim for service connection for PTSD, it is noted that the record contains no mention of the veteran's claimed in-service stressors. Nor has the veteran been examined by a VA psychiatrist in order to establish whether he manifests PTSD. Furthermore, his alleged tinnitus has also never been evaluated by VA. In regard to the veteran's pension claim, it is noted that the exact nature and degree of severity of his various disabilities is clearly pertinent. Therefore, an examination of his various claimed disabilities is essential before a determination as to entitlement to pension can be made. Moreover, VA has a duty to acknowledge and consider all regulations which are potentially applicable based upon the assertions and issues raised in the record and to explain the reasons used to support the conclusion. Schafrath v. Derwinski, 1 Vet.App. 589 (1991). These regulations include, but are not limited to, 38 C.F.R. § 4.1, that requires that each disability be viewed in relation to its history and that there be an emphasis placed upon the limitation of activity imposed by the disabling condition, and 38 C.F.R. § 4.2 which requires that medical reports be interpreted in light of the whole recorded history, and that each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.10 states that, in cases of functional impairment, evaluations are to based upon lack of usefulness, and medical examiners must furnish, in addition to etiological, anatomical, pathological, laboratory and prognostic data required for ordinary medical classification, full description of the effects of the disability upon a person's ordinary activity. This evaluation includes functional disability due to pain under the provisions of 38 C.F.R. § 4.40. These requirements for the evaluation of the complete medical history of the claimant's condition operate to protect claimants against adverse decision based upon a single, incomplete or inaccurate report and to enable VA to make a more precise evaluation of the disability level and any changes in the condition. The RO's attention is also directed to certain cases that relate directly to pension claims. In Roberts v. Derwinski, 2 Vet.App. 387 (1992), the Court held that each disability in a pension case must be assigned a percentage rating, and that the RO should discuss the diagnostic codes used to deny a claim. In addition, in Brown v. Derwinski, 2 Vet.App. 444 (1992), the Court held that a pension claim must be considered under both the average person, 38 U.S.C.A. § 1502(a) (West 1991); 38 C.F.R. § 4.15 (1994), and the unemployability standards, 38 C.F.R. §§ 3.321 and 4.7 (1994). Under the circumstances of this case, the undersigned finds that additional assistance is necessary, and this case is REMANDED to the RO for the following: 1. The RO should contact the veteran and request that he provide as detailed information as possible concerning any alleged inservice stressors. This information should include names and specific dates of any incidents. 2. Once the above-requested information has been obtained and associated with the claims folder, the RO should refer this case to the Environmental Support Group (ESG), 7798 Cissna Road, Springfield, Virginia 22050-3197. The ESG should be requested to verify any claimed stressors. The RO should also undertake any further development that the ESG indicates may be practicable, e.g., inquiry to the National Archives or other historical archives. 3. The RO should contact the veteran and request that he sign and return a consent form authorizing the release to VA of any private outpatient treatment records. Once the consent forms have been received, the RO should contact all indicated physician and treatment facilities and request that they provide copies of the veteran's treatment records. 4. The RO should also inquire of the veteran as to whether he has received any treatment at a VA facility. If he indicates any such treatment, all records should be obtained. 5. Once the above-requested information has been received and associated with the claims folder, the RO should afford the veteran a complete general medical examination, to include special orthopedic (for his right shoulder, low back, cervical spine, left knee and left elbow problems), neurological, audiological, and opthomatological examinations in order to fully evaluate the nature and degree of severity of his various disabilities. All indicated special studies should be accomplished. The examiners should render opinions as to what effect the disabilities found, including any pain attributable thereto, have on the veteran's ability to work and state whether the veteran's disabling conditions are susceptible to improvement through appropriate treatment. The claims folder must be made available to the examiners prior to the examinations so that the veteran's entire medical history can be taken into consideration. 6. The RO should also afford the veteran a complete VA psychiatric examination in order to establish a diagnosis. All special psychological studies, to include, but not limited to, an MMPI, should be conducted. The claims folder must be made available to the examiner prior to the examination so that the veteran's entire history can be taken into consideration. 7. When the requested developments have been completed, the case should be reviewed by the RO and a rating action prepared which lists all the veteran's disabilities and the percentage evaluations assigned to each. If the decision remains adverse to the veteran, he and his representative should be furnished a supplemental statement of the case which includes the percentage rating for each diagnosed disability, which cites the appropriate diagnostic codes and provides a discussion of their applicability to the veteran's disabilities, and which discusses the application of the two standards (average person and unemployability under 38 U.S.C.A. § 1502(a) (West 1991); 38 C.F.R. §§ 3.321, 4.15, 4.17 (1994)) by which a permanent and total disability rating for pension purposes may be assigned. The veteran and his representative should then be given an opportunity to respond. The case should then be returned to the Board for further appellate consideration if otherwise in order. C. P. RUSSELL 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).