BVA9506427 DOCKET NO. 93-14 068 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUE Entitlement to an increased evaluation for residuals of a gunshot wound of the left abdominal wall, currently evaluated as 10 percent disabling. REPRESENTATION Appellant represented by: Marine Corps League ATTORNEY FOR THE BOARD Robert E. O'Brien, Counsel INTRODUCTION The veteran had active service from February 1967 to September 1968. This case comes before the Board of Veterans' Appeals (Board) on appeal from a June 1992 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Detroit, Michigan, which confirmed and continued a 10 percent rating for the veteran's residuals of a gunshot wound to the left abdominal wall. During the pendency of the appeal for an increased rating, service connection for post-traumatic stress disorder was granted by the RO and a 30 percent evaluation was assigned, effective April 3, 1992. The Board also notes that in a February 1993 communication the veteran stated that he wished to amend his claim to include consideration of his entitlement to service connection for a scar in the area of the right eye and lower right temple. He stated that he sustained the injury in January 1968, the same time he was shot in the abdomen. This issue has not been developed or adjudicated for appellate purposes and is referred to the RO for appropriate consideration. REMAND A review of the evidence of record discloses that in July 1992 the veteran underwent a colonoscopy by M. Hurtado, M.D. The rectal sigmoid, descending colon was very spastic. The colon was tortuous and there was great difficulty getting into the transverse and ascending colon. Notation was made that the colon seemed to be distorted. The impression was a probable spastic colon. Notation was made of atonic constipation and a post surgical colon. Recommendations included follow-up visits. In an April 1993 communication the veteran's mother stated that the veteran had constipation so bad that he was taking laxatives every other day. She stated the veteran was thin and was unable to eat very much because he was so bloated. The Board notes that the veteran has not received a VA examination for his service-connected gunshot wound residuals of the abdomen for many years. VA has a duty to assist the veteran in the development of facts pertinent to his claim under 38 C.F.R. § 3.103(a) (1994). The United States Court of Veterans Appeals has held that fulfillment of the VA's duty to assist the veteran includes providing him with a thorough and contemporaneous medical examination. Littke v. Derwinski, 1 Vet.App. 90,92 (1990). In view of the foregoing, the case is REMANDED for the following actions: 1. The RO should contact the veteran and request that he provide the names and addresses of any health care providers who have treated him for the gunshot wound residuals of the left abdominal wall since 1992 and specify the approximate dates of treatment, if possible. Then, after any necessary authorization is obtained from the veteran, the RO should obtain copies of any treatment records identified by him. Of particular interest are any records from M. Hurtado, M.D., subsequent to July 1992. 2. The veteran should then be afforded a surgical examination to determine the nature and severity of all residuals of the January 1968 gunshot wound of the abdomen (characterized as non penetrating in the service medical records). The examiner must be provided the claims folder. The scope of the examination should be broad enough to cover all residual conditions suggested by review of the service medical records and the October 1968 VA examination, as well as those suggested by the veteran's complaints, symptoms or find- ings at the time of examination. The examiner should refer the veteran for examination by other specialists if indicated. The examination should be conducted in accordance with the Physician's Guide for Disability Evaluation Examinations. Based upon review of perti- nent data in the claims folder as well as symptoms and findings at the time of examination, the examiner should identify all manifestations which may be attributable to 1968 gunshot wound of the abdomen. Unretouched photographs of scars attributable to the gunshot wound and laparotomy should be taken and made a part of the records assembled for appellate review. The examiner should specifically rule in or out the presence of gunshot wound damage to internal organs or the intestinal tract. Also, the examiner should state whether or not the scars are tenderness or painful on objective examination. 3. Thereafter, the RO should adjudicate the veteran's claim in light of the additional evidence. The rating decision should reflect consideration of all potentially applicable criteria, to include the applicability of 38 C.F.R. § 3.321(b)(1). If the decision remains adverse to the veteran in any way, he and his representative should be furnished with a supplemental statement of the case which summarizes the pertinent evidence, fully cites the applicable legal provisions and reflects detailed reasons and bases for the decision. They should then be afforded the applicable time period to respond. Thereafter, subject to current appellate procedures, the case should be returned to the Board for further appellate consideration, if appropriate. The veteran need take no action until he is further informed. The purpose of this REMAND is to obtain additional information and to ensure due process of law. No inference should be drawn regarding the final disposition of the claim as a result of this action. GARY L. GICK Member, Board of Veterans' Appeals (CONTINUED ON NEXT PAGE) 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 deter- mination. 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 action has been taken in accordance with the Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 303, 108 Stat. 4645, ___ (1994), and 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).