BVA9505720 DOCKET NO. 91-51 642 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Huntington, West Virginia THE ISSUES 1. Entitlement to service connection for residuals of left shoulder and left elbow injuries, residuals of wine poisoning, residuals of a laceration of the left hand and residuals of venereal warts. 2. Entitlement to an increased evaluation for post-traumatic stress disorder, currently rated 30 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD R. A. Caffery, Counsel INTRODUCTION The veteran had active service from January 1966 to October 1968. He served in Vietnam from November 1967 until October 1968. His listed principal duty was as a supply clerk or handler. His listed awards and decorations do not include any indicative of combat service. In a December 1990 rating action, the Department of Veterans Affairs (VA) Regional Office, Huntington, West Virginia, denied entitlement to service connection for residuals of injuries to the left shoulder and left elbow, residuals of wine poisoning, left hand laceration and venereal warts, and assigned a 10 percent evaluation for post-traumatic stress disorder. Entitlement to a permanent and total disability rating for pension purposes was also denied. The veteran disagreed with the foregoing determinations. In a July 1991 rating action, the evaluation for the veteran's psychiatric condition was increased to 30 percent. In September 1991, he indicated that he wished a still higher rating for the post-traumatic stress disorder. The case was initially before the Board of Veterans' Appeals (Board) in July 1992 when it was remanded for further development. In a March 1993 rating action, the regional office granted a permanent and total disability rating for pension purposes. The denial of the remaining issues on appeal was continued. The case is again before the Board for further appellate consideration. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends, in substance, that service connection should be established for residuals of injuries of his left shoulder and left elbow since they were injured at the same time in May 1968 in Vietnam. He was riding shotgun on a very large and high piece of equipment when a mortar attack occurred and the blast from the incoming round threw him off the side of the equipment. He landed on his left side and sustained the injuries to his left shoulder and left elbow. In 1968, while in Vietnam, he was poisoned on rice wine by some so-called peaceful Vietnamese. He became unconscious and was taken to the hospital. Later, he was informed by a military doctor that he had pumped the poison out of his stomach. He remained on bed rest for a few more days before being allowed to return to duty. Also, while on duty in 1968 in Vietnam, he managed to slice his left hand open and the laceration was sutured at the post hospital. He still has the scar. While on rest and recreation in Malaysia in 1968, he contacted venereal warts which became painful and very sensitive. He went to the post hospital where they were burned off. It is further contended that an increased evaluation should be assigned for post-traumatic stress disorder since the veteran is tense, anxious and depressed. He experiences severe nightmares and flashbacks of his experiences in Vietnam and he has a tendency to self-isolate. It is maintained that the symptoms from the so-called temporary adjustment disorder and depression cannot be disassociated from the veteran's service- connected post-traumatic stress disorder. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991), has reviewed and considered all of the evidence and material of record. Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that the preponderance of the evidence is against the veteran's claims for service connection for residuals of injury to the left shoulder and elbow, residuals of wine poisoning, residuals of a laceration of the left hand and residuals of venereal warts. It is the further decision of the Board that the evidence supports the veteran's claim for an increased evaluation for his post-traumatic stress disorder to 50 percent. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the veteran's appeal has been obtained by the regional office. 2. The veteran was treated during service, in May 1968, for a contusion of the left elbow after he fell on the elbow. No injury to the shoulder was noted at that time. 3. A left elbow or left shoulder condition has not been currently medically shown. 4. Wine poisoning, a laceration of the left hand and venereal warts were not demonstrated during the veteran's military service. 5. Residuals of any such conditions have not been medically demonstrated subsequent to service. 6. The veteran's post-traumatic stress disorder is manifested by symptoms including tension, anxiety, depression, nightmares, flashbacks of Vietnam and the restriction of interpersonal relationships. 7. The veteran's post-traumatic stress disorder is productive of considerable social and industrial impairment. CONCLUSIONS OF LAW 1. The veteran does not have residuals of left shoulder and left elbow injuries, residuals of wine poisoning, residuals of a laceration of the left hand and residuals of venereal warts that were incurred in or aggravated during his active service. 38 U.S.C.A. §§ 1110, 5107 (West 1991); 38 C.F.R. § 3.303 (1993). 2. An evaluation of 50 percent for the veteran's post-traumatic stress disorder is warranted. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. Part 4, Diagnostic Code 9411 (1993). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Board notes that it has found the veteran's claims are "well grounded" within the meaning of 38 U.S.C.A. § 5107(a); effective on and after September 1, 1989. That is, the Board finds that he has presented claims which are plausible. The Board is also satisfied that all relevant facts have been properly developed. I. The Claims for Service Connection for Residuals of Left Shoulder and Left Elbow Injuries, Residuals of Wine Poisoning, Residuals of a Laceration of the Left Hand and Residuals of Venereal Warts The veteran's service medical records reflect that he was seen on an outpatient basis in May 1968 after falling on his left elbow. An X-ray study of the elbow did not reveal any fracture or dislocation. A sling was provided and he was given Darvon. He was seen three days later and it was indicated that he had a contusion of the elbow. He was again seen apparently later in May 1968 and stated that he still could not straighten his arm. He reported slight pain although it was decreasing. Examination showed that he still had stiffness of his arm although he could go through a full range of motion. An exercise plan was suggested. When the veteran was examined for separation from service in October 1968, he reported having or having had a painful or "trick" shoulder or elbow. However, clinical evaluation of the upper extremities was normal on the medical examination. His service medical records do not reflect any report of wine poisoning, a laceration of the left hand or venereal warts. The veteran's initial application for VA disability benefits was submitted in May 1990. He provided statements from several private physicians indicating that he had been treated for an April 1987 injury to his low back while at work. The veteran was examined by the VA in October 1990. His complaints included severe low back pain, bleeding hemorrhoids and diarrhea, and an upset stomach with frequent heart burn and vomiting. The general medical examination was essentially within normal limits except for elevated blood pressure. An upper gastrointestinal X-ray series showed no abnormality of the esophagus, stomach, duodenum and visualized small bowel. On orthopedic examination, the veteran reported dislocating his left shoulder and elbow after being blown off a piece of equipment in 1968 in Vietnam. He indicated that he was hospitalized for 2 or 3 days and returned to duty. He reported that, since then, his left upper extremity had been weaker than the right. It was reported that he was right-handed. He had not seen any doctor about those complaints since the time of the injury. On physical examination of the left shoulder and elbow, there were no deltoid atrophy or tenderness about the shoulder and no crepitus. It was reported that the veteran did not complain of pain, but reported some stiffness on flexion and that there was no limitation of motion of the shoulder. Examination of the left elbow showed no deformity and there was a full range of motion without pain. An X-ray study of the left shoulder and left elbow was within normal limits. The examiner indicated that no abnormality of the left shoulder or left elbow had been found on the examination. Records were subsequently received from the Social Security Administration reflecting that the veteran was treated by various private physicians and at various private hospitals from 1976 to 1990 for various conditions including problems with his low back, left knee and right shoulder and a laceration of his right hand that occurred in September 1978. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by wartime service. 38 U.S.C.A. § 1110. For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." Continuity of symptomatology is required where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). In this particular case, as indicated previously, the veteran's service medical records reflect that he was treated in May 1968 after falling on his left elbow. However, an X-ray study of the elbow did not reveal any fracture or dislocation and the condition was diagnosed as a contusion (a bruise). There is no indication that the injury left any residual disability. The records do not reflect any shoulder injury at that time. Although he referred to having or having had a painful or "trick" shoulder or elbow at the time of his physical examination for separation from service in October 1968, clinical evaluation of the upper extremities was normal. Further, the October 1990 VA orthopedic examination, which included X-rays of the left shoulder and elbow, did not reflect any abnormality of either the left shoulder or elbow. There was a full range of motion of the left elbow and the left shoulder and no pain or tenderness. In the absence of any current pathology involving the veteran's left shoulder and elbow, an evidentiary basis which would warrant service connection for residuals of an injury to the shoulder and elbow is not established. 38 U.S.C.A. § 1110. Under the circumstances, it appears that the inservice injury to the veteran's left elbow in May 1968 was acute and transitory in nature and resolved with treatment, leaving no residual disability. Residual disability is necessary before service connection may be established. With regard to the veteran's claims for service connection for residuals of wine poisoning, residuals of a laceration of the left hand and residuals of venereal warts, his service medical records make no reference to any of those conditions. Further, residuals of wine poisoning, a laceration of the left hand and venereal warts were not demonstrated on the October 1990 VA examination or on the private medical records provided by the veteran. Accordingly, a basis to establish service connection for the claimed residuals has not been established. 38 U.S.C.A. § 1110. The Board has carefully reviewed the entire record regarding the veteran's claim for service connection for the conditions at issue; however, the Board does not find the evidence to be so evenly balanced that there is doubt as to any material issue regarding those matters. 38 U.S.C.A. § 5107. II. The Claim for an Increased Evaluation for Post-Traumatic Stress Disorder A report by the Raleigh County Mental Health Council, dated in January 1990 reflects that the veteran was referred due to depression. It was reported that there was suicidal ideation. His insight and judgment were fair and he had a memory impairment. Another report by the mental health counsel, dated in August 1990, reflects that psychological testing showed that the veteran had a severe degree of manifest depression. The results indicated that a dual diagnoses of dysthymia and alcohol dependence were appropriate. The veteran was afforded a psychiatric examination for the VA in November 1990. It was reported that, after leaving the service, he had worked on a garbage truck for about a year and then had worked in a warehouse for about five years. He then had worked in the coal mines for about four years and had worked at another facility for about two years. He had then worked at a hospital for seven years. His last employment had been at the hospital in 1987. It was stated that he had been married four times. His relationship with his current wife was fair. On mental status examination, the veteran was tense, anxious and fairly depressed with focus on return of his Vietnam symptoms since he had stopped working, stating "I kept my mind by either working or drinking. Now it has come into the limelight." He had difficulty in coping and had become distrustful. No bizarre thought processes were elicited. He denied any active homicidal or suicidal ideation. His insight judgment and problem solving seemed to be poor. It was stated that he currently lived with his wife and two children. He did not abuse alcohol anymore. He used to be outgoing, but had become rather withdrawn. He rarely attended church. He had no particular hobbies. He did not belong to any clubs or organizations. The psychiatric diagnoses were adjustment disorder with mixed emotional features (anxiety and depression secondary to situational factors and physical illness) and post-traumatic stress disorder with history of alcohol abuse, in remission. An April 1991 statement by Ahmed D. Faheem, M.D., a psychiatrist at the Raleigh County Mental Health Council, reflected that the veteran had been involved in regular outpatient treatment at that facility since January 1990. It was stated that the veteran had problems with recurrent severe depression and anxiety. He had recurrent severe nightmares and flashbacks of his experiences in Vietnam. He was unable to concentrate and was easily startled. He had great difficulty tolerating stresses and tended to shy away from people. He had been generally suspicious and distrustful. He had done out of the ordinary things like shooting guns in the air in the middle of the night, scaring his wife and some other people around him. He had begun having so much difficulty being around people that he had moved into the woods where he could live away from everyone. Dr. Faheem stated that a significant amount of the veteran's problems were related to post-traumatic stress disorder. He stated that the severity of his illness was considered to be moderately severe. Dr. Faheem felt that, based on his psychiatric impairment, the veteran was entitled to at least 30 percent to 50 percent service benefits. He stated the veteran was competent to handle his own affairs. In a December 1991 statement, Dr. Faheem indicated that, in spite of intensive treatment on an outpatient basis, the veteran's condition seemed to have been getting progressively worse. He had been unable to sleep at night and tended to get up in the middle of the night with recurrent nightmares. They had had to recently increase his medications which currently included Tofranil, 50 milligrams, three times a day, Mellaril, 25 milligrams, three times a day and Valium, 5 milligrams at night. Dr. Faheem felt that the veteran's condition appeared to be severe. He felt that the veteran should be entitled to 50 percent service-connected benefits. The regional office subsequently received reports of the veteran's treatment at the Raleigh County Mental Health Council from January 1990 to July 1992. Various findings were recorded in May and July 1992 including anxiety and depression. The medical records received from the Social Security Administration reflect copies of the veteran's treatment at the Raleigh County Mental Health Council that had been previously submitted. There was also a copy of the November 1990 examination conducted for the VA and a November 1990 report by the Raleigh County Mental Health Council reflecting that the veteran had been initially treated at that facility in January 1990 due to depression. The veteran was again afforded a VA psychiatric examination in February 1993. The veteran stated that he had been under constant stress in Vietnam not knowing whether he would make it through the day alive or not. He stated that he had flashbacks of Vietnam practically every day. He related that, after service, the only job he could obtain was working on the garbage truck, collecting garbage. He stated that he had great difficulty adjusting to civilian life. He drank heavily to control his nerves and became an alcoholic. The veteran stated that he was puzzled and did not know what was causing him to do the things he did until he obtained treatment and some understanding about four years previously. It was stated that the veteran had been easily agitated and went into rage-like episodes. He stated that he had no friends and was a loner. He indicated that, because of his temper and difficulty getting along with people, they had to live away from people. The veteran related that he was on edge most of the time and could not sleep at night. He had recurrent nightmares that scared him. He had flashbacks about Vietnam. He was very withdrawn and easily irritated. His wife came in with him and indicated that the veteran had just not been himself. He got into severe depression. He stated that "All I do in an average day is look out the window and wait for it to be over." He felt that no one liked him because he was a Vietnam veteran. He related that he used to drink to calm his nerves, but had not done that lately. His wife came with him to the interview and was supportive and gave most of the information. The veteran appeared to be tense, anxious, edgy and depressed. He was not under the influence of alcohol. He was oriented for time, place and person and there was no evidence of active hallucinations or delusions. His attention and concentration were impaired. His memory and recall for recent events was impaired. There was no evidence of looseness of associations or pressured speech. His fund of knowledge was appropriate for his educational background. He denied being actively suicidal or homicidal. There were no excessive compulsive actions. He was considered competent for VA purposes. The pertinent diagnosis was post-traumatic stress disorder. A 30 percent evaluation is warranted for post-traumatic stress neurosis (post-traumatic stress disorder) when there is definite impairment in the ability to establish or maintain effective and wholesome relationships with people and when psychoneurotic symptoms have resulted in such reduction in initiative, flexibility, efficiency and reliability levels as to produce definite industrial impairment. A 50 percent evaluation requires that the ability to establish or maintain effective or favorable relationships with people is considerably impaired and reliability, flexibility and efficiency levels are so reduced by reason of psychoneurotic symptoms as to result in considerable industrial impairment. 38 C.F.R. Part 4, Code 9411. In this particular case, the evidence reflects that the veteran's post-traumatic stress disorder has resulted in symptoms including tension, anxiety, depression, nightmares and flashbacks of his Vietnam experiences and a restriction of his interpersonal relationships. He has not been employed for several years since suffering on-the-job back injuries. It appears that his unemployment is due to multiple factors including nonservice- connected disabilities with his service-connected psychiatric disorder playing only a small role. The evidence in the Board's judgment, however, indicates that the veteran's post-traumatic stress disorder is now productive of considerable social and industrial impairment. Accordingly, entitlement to the next higher evaluation of 50 percent for the post-traumatic stress disorder under Diagnostic Code 9411 is in order. The Board does not find that the veteran's psychiatric condition has resulted in severe social and industrial impairment so as to warrant entitlement to the next higher evaluation of 70 percent under that diagnostic code. In arriving at its decision regarding the veteran's claim for an increased rating of his post-traumatic stress disorder, the Board has resolved all doubt in his favor. 38 U.S.C.A. § 5107. ORDER Entitlement to service connection for residuals of left shoulder and left elbow injuries, residuals of wine poisoning, residuals of a laceration of the left hand and residuals of venereal warts is not established. The appeal is denied to this extent. Entitlement to an increased evaluation for post-traumatic stress disorder from 30 percent to 50 percent disabling is established. The appeal is granted to this extent. ROBERT D. PHILIPP 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. NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991), a decision of the Board of Veterans' Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans' Judicial Review Act, Pub. L. No. 100-687, § 402 (1988). The date which appears on the face of this decision constitutes the date of mailing and the copy of this decision which you have received is your notice of the action taken on your appeal by the Board of Veterans' Appeals.