BVA9504070 DOCKET NO. 91-10 847 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to service connection for defective vision involving the left eye. 2. Entitlement to service connection for bilateral hearing loss. 3. Entitlement to service connection for degenerative joint disease of the cervical spine. 4. Entitlement to service connection for gastroenteritis. 5. Entitlement to service connection for residuals of hookworm infection. 6. Entitlement to service connection for a skin disorder. 7. Whether new and material evidence has been submitted in order to reopen a claim of entitlement to service connection for amoebic dysentery. 8. Entitlement to an increased evaluation for residuals of a shell fragment wound to the left arm, currently evaluated as 20 percent disabling. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARINGS ON APPEAL Appellant ATTORNEY FOR THE BOARD Robert P. Regan, Counsel INTRODUCTION The appellant served on active duty from October 1941 to January 1946. This matter came before the Board of Veterans' Appeals (Board) on appeal of a February 1988 rating determination by the Department of Veterans Affairs (VA) Regional Office (RO) located in Atlanta, Georgia. This case was before the Board in October 1991 at which time the Board allowed entitlement to service connection for tinnitus in the left ear as a result of a concussion or acoustic trauma which occurred during active duty. This is a complete grant of the benefit sought regarding this issue. This issue is no longer in appellate status. During the appellant's hearing in April 1994 before a member of the Board sitting at Washington, D. C., he testified that he had a claim of entitlement to service connection for headaches pending at the RO and gave testimony regarding this issue. This testimony is referred to the RO for appropriate action in conjunction with the appellant's claim of entitlement to service connection for headaches. He further testified that he believed his duodenal ulcer had been caused by the gastrointestinal problems which he experienced while on active duty. This issue has not been developed for appellate consideration and is referred to the RO for appropriate action The record reflects that private medical statements received in 1994 contain references to a low back disability which was the result of inservice injuries. It is requested that the RO contact the appellant in order to determine if he is claiming service connection for a low back disability and, thereafter, take the appropriate action. REMAND Initially, the Board has found that the appellant's claims are well grounded pursuant to 38 U.S.C.A. § 5107 (West 1991) in that his claims are plausible or capable of substantiation Murphy v. Derwinski, 1 Vet.App. 78 (1990). This finding is based, in part, on the appellant's testimony given during his hearing and authorizations for Release of Information forms which were received in January 1992. In these forms the appellant indicates he received medical treatment from several private physicians following his release from active duty. This information, if available, could also be of assistance to the appellant in his attempt to reopen his claim of entitlement to service connection for amoebic dysentery. Ivey v. Derwinski, 2 Vet.App. 320 (1992). In this regard, it is noted that the appellant during his hearing in April 1994, indicated that C. R.. Cooper, D.C. had destroyed the old treatment records. The record also shows that a portion of the private treatment records listed on these forms are on file. Once it has been determined that a claim is well grounded, VA has a statutory duty to assist the appellant in the development of evidence pertinent to that claim. 38 U.S.C.A. § 5107. The appellant is contending, in part, that his hearing loss and his cervical spine disability are the result of injuries he sustained, when he was thrown approximately 30 feet when wounded by a mortar shell explosion. A review of the service medical records reflects that the appellant received treatment in February 1945 for shell fragment wounds to the abdomen and arm. He was transferred to the 3rd Marine Division Field Hospital. These hospital records are not on file. During the appellant's hearing in Washington, D.C., he testified that he did receive treatment for approximately two days on board a hospital ship for these injuries. These records are not on file. The appellant has submitted several private medical statements which are to the effect that the appellant's cervical spine disability, hearing loss in the left ear and decreased vision in the left eye are the result of the injuries the appellant sustained while on active duty. The private medical records show that the appellant has been treated for skin cancer. A private physician, in a July 1992 statement, indicates that the appellant skin disorders, including cancer, are the result of actinic exposure during the appellant's service in the Pacific Theatre. A review of the September 1989 VA examination reflects that the appellant has a shell fragment wound scar located on the left forearm, dorsal aspect, and on the ventral side of his left upper arm. The service-connected shell fragment wound to the left arm is currently rated as 20 percent disabling under Diagnostic Code 5303, which provides for the evaluation of the injury to Muscle Group III, the intrinsic muscles of the shoulder girdle. The function of Muscle Group III is the elevation and abduction of the arm to the level of shoulder in conjunction with other muscle groups, and the forward and backward swing of the arm. 38 C.F.R. § 4.73 (1993). The shell fragment wound to the forearm, if in fact there is any muscle injury, would involve the functions of the wrist and fingers which are separate from the function of Muscle Group III. Thus, the Board is of the opinion that the RO should assign separate disability ratings for the shell fragment wounds. The Board is also of the opinion that a thorough and a contemporaneous VA examination would be of assistance in rendering a determination in this case. The appellant during his hearing in April 1994, indicated that he was examined by an ophthalmologist, who was located in Georgia, shortly after his release from active duty. These records are not on file. In accordance with the statutory duty to assist the appellant in the development of evidence pertinent to his claim, the case is REMANDED for the following actions: 1. The RO should request the appellant to furnish any additional information which would assist in identifying the hospital ship where the appellant was treated in 1945 for the shell fragment wounds. 2. Thereafter, the RO should request the National Personnel Records Center in St. Louis, Missouri, to conduct a search for any additional service medical records, to include the hospital records from the 3rd Marine Division Hospital where the appellant was transferred on February 27, 1945, and the hospital ship where the appellant was apparently hospitalized in the same time frame. 3. The RO is requested to obtain copies of the actual treatment records from Dr. Olmstead, 1946 to 1948; Dr. D. W. Connell, 1957 to 1962; Dr. E. F. Donning, 1969 to 1989; Dr. S. Rosenthal, 1957 up to the present; Dr. P. Jurgensen, 1955 to 1984; and Dr. C. T. Tucker, 1991 up to the present. (See VA Forms 21-4142, dated June 16, 1992). 4. The RO should also furnish the appellant appropriate Release of Information forms in order to obtain copies of the medical records regarding the appellant's treatment by the ophthalmologist in Georgia shortly after his release from active duty. The appellant should also be informed that he has the opportunity to submit any additional evidence in support of his claims. 4. The RO should request the VA medical facility located in Augusta , Georgia to furnish copies of any additional medical and hospital records regarding treatment subsequent to June 1991. 5. VA examinations should be conducted by an orthopedist and neurologist in order to determine the nature and severity of the residuals of the shell fragment wounds to the left arm. All testing deemed necessary should be performed. The claims folder is to be made available to the examiners in conjunction with their examinations. It is requested that the orthopedist identify all muscle groups injured by the shell fragment wounds to the left upper arm and left forearm and describe any functional impairment resulting from said shell fragment wounds. The orthopedist, in conjunction with the review of the record, is requested to render an opinion as to whether it is as likely as not that the degenerative joint disease of the cervical spine was caused by the injuries the appellant sustained in February 1945 when struck by shell fragments from a mortar round and thrown approximately 30 feet. The examiner should include a rationale for the opinion. 6. A VA examination should be conducted by a specialist in ear disorders in order to determine the nature and severity of the appellant's hearing loss. An audiological evaluation and any other tests deemed necessary should be performed. In conjunction with the review of the appellant's claims folder, it is requested that the examiner render an opinion as to whether it is as likely as not that any hearing loss found during the examination is causally related to the acoustic trauma the appellant sustained in service, to include the explosion of the mortar round in February 1945. The examiner is to include the rationale on which the opinion is based. 7. A VA examination should be conducted by an ophthalmologist in order to determine the nature and severity of any disability involving the left eye. All testing deemed necessary should be performed. In conjunction with the review of the appellant's claims folder, it is requested that the examiner render an opinions as to when any eye disability diagnosed was initially clinically manifested and whether it is as likely as not that any disability found during the examination involving the left eye is related to any incident which occurred during active duty, to include the incident when the appellant sustained shell fragment wounds to the left arm and abdomen. The examiner should include the rationale upon which the opinion is based. 8. A VA examination should be conducted by a dermatologist in order to determine the nature and severity of any skin disorders. All testing deemed necessary should be performed. In conjunction with a review of the claims folder, it is requested that the examiner render an opinion as to whether it is as likely as not that the appellant's skin disorders are related to his military service, to include actinic exposure during his service in the Pacific Theatre. The examiner should include the rationale on which the opinion is based. 9. The RO is requested to furnish the VA examiners a copy of this remand. 10. Thereafter, these issues should be readjudicated by the RO. It is requested that the RO also assign separate rating disability percentages for the shell fragment wound to the left upper arm and left forearm. The RO should also make a determination as to whether the appellant's skin cancer was manifested during service or within one year following the appellant's release from active duty. If the benefits sought are not granted, the appellant and his representative should be furnished a supplemental statement of the case and opportunity to respond. The supplemental statement of the case is to include appropriate law and regulation regarding entitlement to service connection for a chronic disease (cancer) on a presumptive basis under 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 1991); 38 C.F.R. §§ 3.307, 3.309 (1993), and the rating criteria for an increased evaluation for the shell fragment wound to the left forearm. The case should then be returned to the Board for further appellate consideration. RICHARD B. FRANK 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) (1993).