BVA9507317 DOCKET NO. 93-08 188 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Whether new and material evidence has been submitted to reopen a claim of entitlement to service connection for post- traumatic stress disorder. 2. Whether new and material evidence has been submitted to reopen a claim of entitlement to service connection for a hearing loss of the right ear. 3. Entitlement to service connection for defective vision. 4. Entitlement to an increased evaluation for hypertension, currently evaluated as 10 percent disabling. 5. Entitlement to an increased evaluation for cephalgia, possibly migraine, currently evaluated as 10 percent disabling. 6. Entitlement to an increased (compensable) evaluation for hearing loss of the left ear. 7. Entitlement to an increased (compensable) evaluation for residuals of a fracture of the 5th metatarsal of the left foot. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Ronald R. Bosch, Counsel INTRODUCTION The veteran served on active duty from July 1966 to June 1969 and from September 1971 to October 1977. The claims file contains a report of a Board of Veterans' Appeals (Board) decision dated in December 1988 denying entitlement to service connection for a hearing loss of the right ear. The claims file contains a report of a Board decision dated in January 1990 denying entitlement to service connection for post- traumatic stress disorder. This appeal arose from an August 1990 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia. The RO, in pertinent part, affirmed the previous denial of entitlement to service connection for post- traumatic stress disorder, continued the previous denial of entitlement to service connection for a hearing loss of the right ear, denied entitlement to service connection for defective vision, and denied entitlement to increased evaluations for hypertension, cephalgia, and hearing loss of the left ear. It was noted erroneously that service connection for residuals of a fracture of the fifth metatarsal of the left foot remained denied; however, this was corrected in a rating decision issued in March 1992. In his April 1992 appeal statement to the Board, the veteran noted that his ears had begun to ring. The Board construes this statement as an inferred claim for service connection for tinnitus. This issue has neither been prepared nor certified for appellate review. The Board is referring it to the RO for appropriate action. REMAND A review of the record discloses that when examined by VA in August 1987, the veteran was found to meet the criteria for a diagnosis of post-traumatic stress disorder. In a statement on appeal, the veteran stated that he had been diagnosed three times with post-traumatic stress disorder by VA psychiatrists. He noted that his last diagnosis had been provided quite recently. This evidence is not of record. The claims file contains several stressor statements from the veteran in addition to documentation referable to combat operations of his units in Vietnam. Verification of the veteran's alleged stressors has not been obtained by the RO. The veteran was last formally examined by VA in May 1990. The examiner noted that the claims file was not available for review. See, e.g., 38 C.F.R. § 4.1 (1994) ("It is...essential both in the examination and in the evaluation of the disability, that each disability be viewed in relation to its history.") See also Green v. Derwinski, 1 Vet.App. 121, 124 (1991) ([F]ulfillment of the statutory duty to assist...includes the conduct of 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." (emphasis added)). The examiner noted that the veteran was to undergo a neurologic examination for his headaches. Such examination, if it was conducted, is not of record. The appellant has complained that the VA medical evidence of record is very much dated and does not give an accurate assessment of the current severity of his disabilities. The Board also notes that the veteran has not been specifically examined as to the severity of his left foot disability, and that the medical evidence pertaining to his headaches is inadequate for rating purposes. Therefore, pursuant to VA's duty to assist the veteran in the development of facts pertinent to his claims under 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. § 3.103(a) (1994), the Board will not decide at this time the issues certified for appellate review pending a REMAND of the case to the RO for further development as follows: 1. The RO should request from the veteran a statement containing as much detail as possible regarding any and all stressful events to which he was exposed in service. The veteran should be asked to provide specific details of the claimed stressful events during service, including dates, places, detailed descriptions, units of service, duty assignments, as well as the names, ranks, unit of assignment and any other identifying information concerning other individuals involved in the events. The RO should also request that the veteran provide additional information pertaining to his most recently provided diagnosis of post-traumatic stress disorder by a VA psychiatrist as so alleged. 2. After obtaining the foregoing requested information, the RO should forward it with copies of the veteran's service medical and personnel records including copies of his DD 214's to the United States Army & Joint Services Environmental Support Group (ESG), 7798 Cissna Road, Springfield, Virginia 22150. Any information obtained is to be associated with the claims folder. 3. Following receipt of the ESG's report, and the completion of any additional development warranted or suggested by that office, the RO should prepare a report detailing the nature of any combat action, or inservice stressful event, verified by the ESG. If no combat or stressor has been verified, the RO should so state in their report. This report is then to be added to the claims folder. 4. Then, and only then, should the RO schedule the veteran for a VA psychiatric examination by a board of psychiatrists who have not previously seen or treated him. This examination is to be conducted in accordance with the VA Physician's Guide for Disability Evaluation Examinations in order to determine the nature and extent of any psychiatric disorder which may be present. All indicated studies, including post-traumatic stress disorder sub scales, are to be performed. The claims file must be provided to and reviewed by the examiners prior to conducting their examinations. In determining whether or not the veteran has post-traumatic stress disorder due to an inservice stressor the examiners are hereby notified that only the verified history detailed in the reports provided by the ESG and/or the RO may be relied upon. If the examiners believe that post-traumatic stress disorder is the appropriate diagnosis they must specifically identify which stressor(s) detailed in the ESG's and/or the RO's report is responsible for that conclusion. Any and all opinions expressed must be accompanied by a complete rationale. 5. Following the completion of the foregoing the RO should review the claims file to ensure that all of the foregoing development has been completed in full. In particular, the RO should review the VA psychiatric examination reports to verify that any diagnosis of post-traumatic stress disorder was based on the verified history provided by the ESG and/or the RO. If the examiners relied upon a history which is not verified, that examination report must be returned as inadequate for rating purposes. The Board emphasizes that the United States Court of Veterans Appeals has held that a diagnosis of post-traumatic stress disorder, related to service, which is based on an examination which relied upon an unverified history is inadequate. West v. Brown, 7 Vet.App. 70, 78 (1994). 6. The RO should request and associate with the claims file the report of a VA neurologic examination of the veteran which is reported to have been scheduled in May 1990. 7. The RO should schedule the veteran for a neurological examination to determine the extent of severity of his cephalgia, possibly migraine. The examination is to be conducted in accordance with the diagnostic procedures outlined in the VA Physician's Guide for Disability Evaluation Examinations. All indicated studies are to be conducted. The claims file must be made available to and reviewed by the examiner prior to the examination. 8. The veteran should be scheduled for a medical examination by VA to determine the extent of severity of his hypertension and residuals of a fracture of the 5th metatarsal of the left foot. The examination is to be conducted in accordance with the diagnostic procedures outlined in the VA Physician's Guide for Disability Evaluation Examinations. All indicated studies are to be conducted. The claims file must be made available to and reviewed by the examiner prior to the examination. 9. The RO should review the examination reports to confirm that they are in accordance with the above directives and if not, the examinations should be returned for corrective action. 10. After undertaking any development deemed appropriate in addition to that specified above, the RO should readjudicate the issues of whether new and material evidence has been submitted to reopen a previously denied claim of entitlement to service connection for post-traumatic stress disorder, and increased evaluations for hypertension; cephalgia, possibly migraines; and residuals of a fracture of the 5th metatarsal of the left foot. If the benefits requested on appeal are not granted to the veteran's satisfaction, the RO should issue a supplemental statement of the case. A reasonable period of time for a response should be afforded. Thereafter, the case should be returned to the Board for further appellate review, if otherwise in order. By this REMAND, the Board intimates no opinion as to any final outcome warranted. No action is required of the veteran until he is notified by the RO. ALBERT D. TUTERA 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).