BVA9506044 DOCKET NO. 93-07 044 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to an increased evaluation for hypertension, currently evaluated 10 percent disabling. 2. Whether new and material evidence has been submitted sufficient to reopen a claim of service connection for arthritis of multiple joints. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD M. M. Wernimont, Associate Counsel INTRODUCTION The veteran's active military service extended from December 1948 to September 1952, and from January 1953 to August 1964. A December 1964 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida, in part, granted service connection for hypertension for which a noncompensable evaluation was established. A September 1986 rating decision by the RO, in part, increased the disability evaluation for the veteran's hypertension to 10 percent. The rating decision also denied service connection for multiple arthritis of the spine. The veteran was notified of the decision in October 1986 and he did not appeal within the statutory time limit. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 1992 rating decision by the RO which, in part, continued a 10 percent evaluation for hypertension, and which continued to deny service connection for arthritis of multiple joints (previously characterized as arthritis of the spine). REMAND The RO's September 1986 rating decision and the subsequent notice to the veteran via a letter dated in October 1986 were based upon the results of VA examinations conducted in August 1986. At that time, the veteran complained of severe pain in all joints. During a VA orthopedic examination, the veteran reported pain all over his body, especially pain of both knees which radiated to the toes, and pain of both shoulders which radiated to the hands. The orthopedist's diagnoses included probable osteoarthritis, throughout the spine; status post-injury to both knees with medial collateral ligament tears; and peculiar spotty hypoesthesia of the extremities. A VA radiologist stated that X- rays of the veteran's lumbar spine conducted in August 1986 did not reveal evidence of fracture, subluxation or spondylolisthesis. Rather, radiographic studies indicated that the sacroiliac joints were well-maintained and that minimal early calcification was present throughout the abdominal aorta. X-rays of the right elbow taken at that time revealed no evidence of fracture, subluxation or other significant abnormality. X-rays of both knees suggested early narrowing of the joint space in its medial compartments, bilaterally, somewhat more marked on the right, consistent with early osteoarthritis. Calcification in the arteries posterior to the right knee was noted. X-rays of both ankles revealed no findings of note, and an X-ray of the right hand revealed no evidence of fracture, subluxation or other significant joint pathology. The radiologist did not have access to the results of the orthopedic examination. The basis for the denial of service connection at that time was that the episodes of spinal pain in service were acute and transitory and the probable arthritis of the spine was not noted in service. The RO also held that there was no indication that pain in the hips, legs and ankles was incurred in service. There is considerable confusion in the records contained in the claims folder. There are multiple copies of the same evidence submitted by the veteran. There also appears to be some records relating to service which the veteran has submitted which were not part of the service medical records on file. The service medical records contain diagnoses of arthritis of the spine and joints but the actual examination or X-ray reports which led to these diagnoses are not in the record. In view of the inconsistency as to the diagnosis of arthritis, it is necessary to obtain medical opinions with respect to this diagnosis. In order for the specialists to prepare an opinion it will be necessary for them to have a clear chronological record to review. Service connection has been in effect for hypertension for over 30 years. There has been no recent detailed examination which contains a description of the extent of the hypertension and whether there have been any cardiovascular complications which have developed over the years. The veteran contends that he has submitted new and material evidence sufficient to reopen a claim of service connection for arthritis of unspecified multiple joints. As a result, it is necessary to determine the identity of the veteran's current diagnoses including the type of arthritis present, the specific joint(s) affected by arthritis, and the relationship, if any, between such symptomatology and the symptomatology reported during the veteran's military service. These questions must be resolved by a VA orthopedist and radiologist. Therefore, we find that an appellate determination on the merits of this case is premature at this time. To ensure that VA has met its duty to assist the claimant in developing the facts pertinent to the claim and to ensure full compliance with due process requirements, the case is REMANDED to the regional office for the following development: 1. The RO should obtain the names and addresses of all medical care providers, both VA and private, who treated the veteran for hypertension and for multiple joint arthritis since his separation from service in August 1964. After securing the necessary releases, the RO should obtain copies of those records which are not already of record and add them to the claims file. 2. The RO should contact the service department and request any additional medical records. The RO should also attempt to obtain all X-rays taken while the veteran was on active duty. Similarily, the RO should contact all health care providers both private and VA who have treated or examined the veteran since his separation from service and request them to furnish any X-rays taken. 3. The RO must carefully review and reconstitute the claims folder in chronologic order. All duplicate records should be annotated as such and those records submitted by the veteran should be filed separately with each submission being put in chronologic order. 4. Following the above, the veteran should be accorded an examination by a VA orthopedist to determine the nature and extent of any joint disease, including the type(s) of arthritis present (traumatic or generalized) with the identities of the specific joint(s) affected. The claims folder and a copy of this remand must be made available to and reviewed by the examiner prior to the examination. All necessary tests, including X-rays, should be conducted and the examiner should review the results prior to completion of the report. All examination findings should be reported in detail. The orthopedist and radiologist must confer following their examinations and review any X-rays which have been obtained pursuant to this remand or examination and present opinions as to whether the veteran currently has any joint pathology and whether it is related to any episode or diagnosis in service. Specifically, the physicians must take into account the diagnoses of arthritis made both by military and private physicians during the period from 1962 to 1965 including a report from Fred E. Brammer, M.D. The veteran has submitted evidence for the record on this point. They must discuss the likelihood that the diagnosis of arthritis in service was correct. With respect to the internal derangement of the knees for which service connection has been granted, the examiners must indicate whether this represents an arthritic process and whether it is related to any arthritis found elsewhere. If X-rays could not be obtained pursuant to the development portion of this remand, the examiners should prepare their opinions based on the medical evidence of record and they should provide rationales for all diagnoses and conclusions made. 5. The veteran should also be accorded a special cardiovascular examination to determine the nature and extent of the service-connected hypertension as well as any complications which may be present. The claims folder and a copy of this remand must be made available to and reviewed by the examiner prior to the examination. All necessary tests should be conducted and the examiner should review the results of the testing prior to completion of the report. The report of examination should contain a detailed account of all manifestations of hypertension including any cardiovascular complications. Special attention should be given to obtaining an accurate history as to the type and dosage of medication taken by the veteran for hypertension. With respect to taking the veteran's blood pressure, the guidelines set forth in Physician's Guide for Disability Evaluation Examinations, VA IB 11-56, Chapter 6, Section III should be followed including calling the veteran back on subsequent days, if indicated. The examiner should assess the severity of the overall cardiovascular condition. The report of examination should contain complete rationale for all conclusions reached. 6. The RO should review the claims folder and ensure that all of the foregoing development actions have been conducted and completed in full. If any development is incomplete, appropriate corrective action is to be implemented. Specific attention is directed to the examination reports. If any requested examination does not include fully detailed descriptions of pathology and all test reports, special studies or adequate responses to the specific opinions requested, the report must be returned for corrective action. 7. Subsequently, the RO should consider the question of whether there is new and material evidence to reopen the veteran's claim for service connection for arthritis of multiple joints. If there is, and the claim is reopened, the RO should then adjudicate the claim on the basis of all the evidence of record. The RO should also consider entitlement to an increased rating for hypertension. In so doing, they should formally adjudicate service connection for any cardiovascular pathology found on examination. After the development requested above has been completed, the RO should again review the evidence and determine whether any of the benefits may be granted. If any benefit sought on appeal, for which a notice of disagreement has been filed, remains denied, the appellant and his representative should be furnished a supplemental statement of the case and given the opportunity to respond thereto. Thereafter, the case should be returned to the Board, if in order. The Board intimates no opinion as to the ultimate outcome of this case. The appellant need take no action unless otherwise notified. JAN DONSBACH 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).