BVA9504571 DOCKET NO. 93-08 952 ) 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 a right ankle disability. 2. Entitlement to an increased rating for post-traumatic stress disorder, currently evaluated as 50 percent disabling. 3. Entitlement to an increased rating for residuals of a shell fragment wound of the right upper arm and chest wall, currently evaluated as 30 percent disabling. 4. Entitlement to an increased rating for residuals of a shell fragment wound of the chest, pleural cavity injury, with right hemothorax and paralysis of the right hemidiaphragm with scar, currently evaluated as 20 percent disabling. 5. Entitlement to an increased rating for shell fragment wound scar of the left upper arm, currently evaluated as 10 percent disabling. 6. Entitlement to a total disability rating based on individual unemployability due to service-connected disability. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant and his mother ATTORNEY FOR THE BOARD James R. Siegel, Counsel INTRODUCTION The veteran served on active duty for more than three years, including the period from February to August 1991. This matter comes before the Board of Veterans' Appeals (the Board) on appeal from decisions from the Regional Office (RO). By initial rating decision of September 1991, the RO granted service connection, and assigned the evaluations listed for the following disabilities: post-traumatic stress disorder (PTSD), rated 50 percent disabling; residuals of a shell fragment wound of the chest, with right hemothorax and paralysis of the right hemidiaphragm, rated 20 percent disabling; residuals of a shell fragment wound of the right upper arm (major), rated 10 percent disabling; tinnitus, rated 10 percent disabling; scar, residuals of a shell fragment wound of the left upper arm and left wrist, each rated noncompensable; and bilateral hearing loss, rated noncompensable. By rating decision in July 1992, the RO denied service connection for a right ankle disability and a total disability rating based on individual unemployability due to service-connected disability. Following the receipt of additional evidence, and the veteran's testimony at a September 1992 hearing, a hearing officer granted service connection for a second scar of the left upper arm. A 10 percent rating was assigned the shell fragment wound of the loer part of the left upper arm, and a noncompensable evaluation was assigned the shell fragment wound scar of the left arm (deltoid area). In addition, the hearing officer assigned a 30 percent evaluation for residuals of a shell fragment wound of the right upper arm and chest wall. The foregoing was effectuated by a December 1992 rating decision . By subsequent rating decision in March 1993, the RO denied service connection for a right leg disability, and granted service connection for a surgical scar on the medial and inferior sides of the right scapula, as part and parcel of the previously service-connected shell fragment wound residuals of the right upper arm and chest wall. During the hearing at the RO, the veteran related that he was having problems with his lower back. (See Transcript p. 13.) When the veteran's representative submitted a claim of service connection for a back disability later that month, he did not specify what portion of the back was involved. The RO's attention is directed to this matter for the purpose of clarification. REMAND The initial question before the Board is whether the veteran has submitted a well-grounded claim as required by 38 U.S.C.A. § 5107 (West 1991). A well-grounded claim is one which is plausible or capable of substantiation. Murphy v. Derwinski, 1 Vet.App. 78 (1990). In this case, the veteran's evidentiary assertions concerning the severity of his service-connected disabilities that are within the competence of a lay party to report are sufficient to conclude that his claims are well grounded. King v. Brown, 5 Vet.App. 19 (1993); Proscelle v. Derwinski, 2 Vet.App. 629 (1992); Espiritu v. Derwinski, 2 Vet.App. 492 (1992). The veteran's discharge certificate from his period of service in 1991 discloses that he had an additional three-year period of active service. His dates of service for that period of service have not been verified. In addition, the Board notes that while some service medical records from that initial period of service are of record, it does not appear that all such records have been obtained. When the veteran was afforded a psychiatric examination by the Department of Veterans Affairs (VA) in February 1992, the examiner diagnosed PTSD, assigned a Global Assessment of Functioning (GAF) score of 90 and concluded that PTSD resulted in mild impairment. The examiner commented that it appeared that the symptom complex was improving. However, when the veteran testified at the hearing at the RO in September 1992, he stated that he continued to have nightmares and that he was unable to sleep well. Similarly, the veteran has argued that he sustained an injury to his lung, and that the residuals have increased in severity. The Board also notes that although service connection has been established for a pleural cavity injury, the veteran has not been examined by a specialist in pulmonary disease. When the veteran claims that a disability is worse than when originally rated, and the available evidence is too old to adequately evaluate the current state of the condition, the VA must provide a new examination. Olsen v. Principi, 3 Vet.App. 480, 482 (1992). Here, the most recent VA psychiatric examination is dated in February 1992, and the appellant has made evidentiary assertions that his condition has increased in severity since that time. Finally, it is noted that the residuals of a shell fragment wound of the right upper arm and chest wall has been evaluated pursuant to the provisions of Diagnostic Codes 5302 and 5303 of the VA's Schedule for Rating Disabilities, 38 C.F.R. Part 4 (1994). One shell fragment wound of the left upper arm is evaluated pursuant to Code 5305, while the scar of the deltoid area of the left upper arm is rated under Code 7805. The Board points out, however, that the veteran has not been furnished with the provisions of these diagnostic codes in either the statement of the case or the supplemental statement of the case. In addition, it is not clear if the veteran is appealing the evaluation of both scars of the left upper arm. The VA has a duty to assist the veteran in the development of facts pertinent to his claim. 38 U.S.C.A. § 5107(a) (West 1991). The duty to assist the veteran in obtaining and developing available facts and evidence to support his claim includes obtaining an adequate VA examination. This duty is neither optional nor discretionary. Littke v. Derwinski, 1 Vet.App. 90 (1990). It includes providing additional VA examinations by a specialist, when recommended. Hyder v. Derwinski, 1 Vet.App. 221 (1991). The fulfillment of the statutory duty to assist includes conducting a thorough and contemporaneous medical examination, one which takes into account the records of prior medical treatment, so that the evaluation of the claimed disability will be a fully informed one. Green v. Derwinski, 1 Vet.App. 121, 124 (1991). Under the circumstances of this case, the Board finds that additional development of the record is required. Accordingly, the case is REMANDED to the RO for action as follows: 1. The RO should attempt to verify, through the usual, official channels, the service dates for the veteran's first period of service, and obtain all service medical records therefrom. If there are any additional clinical entries pertaining to the veteran's right ankle, the RO should then readjudicate his claim of entitlement to service connection therefor. 2. The RO should request that the veteran clarify whether he is pursuing his appeal for increased ratings with respect to each shell fragment wound scar of the left upper arm. 3. The RO should contact the veteran and request that he furnish the names, addresses, and approximate dates of treatment of all medical providers from whom he has received treatment for his service- connected disabilities since 1993. After securing the necessary authorization for release of this information, the RO should seek to obtain copies of all treatment records referred to by the veteran. 4. The veteran should then be afforded a VA examination by specialists in pulmonary disease and general surgery, if available, to determine the nature and extent of the residuals of his shell fragment wounds. All necessary tests should be performed. The claims folder should be made available to the examiners in conjunction with the examinations. 5. The veteran should then be afforded a VA psychiatric examination to determine the nature and severity of the manifestations of his PTSD. The examination report should include a detailed account of all pathology found to be present. If there are different psychiatric disorders than PTSD, the examiner should reconcile the diagnoses and should specify which symptoms are associated with each of the disorder(s). If certain symptomatology cannot be dissociated from one disorder or another, it should be specified. The psychiatrist should describe the to which the symptoms of PTSD adversely affect the veteran's social and industrial capacity. The report of the examination should include a complete rationale for all opinions expressed. All necessary special studies or tests should be accomplished. The examiner should assign a numerical code under the GAF scale provided in the Diagnostic and Statistical Manual for Mental Disorders (Third Ed. Revised) (DSM-III-R). It is imperative that the physician include a definition of the numerical GAF Scale code assigned under DSM-III-R in order to comply with the requirements of Thurber v. Brown, 5 Vet.App. 119 (1993). The entire claims folder and a copy of this Remand must be made available to the examiner for review in conjunction with the examination. 6. The RO should prepare a supplemental statement of the case which summarizes the additional evidence received and which includes the diagnostic criteria of Codes 5302, 5303 and 7805. Following completion of the development requested above, the RO should again review the evidence and determine whether the veteran's claim may now be granted. If any benefit sought on appeal remains denied, the veteran and his representative should be furnished a supplemental statement of the case and given an opportunity to respond thereto. The case should then be returned to the Board for further appellate consideration. J.F. GOUGH 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).