BVA9507816 DOCKET NO. 93-14 589 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUE 1. Entitlement to service connection for the residuals of an appendectomy. 2. Entitlement to service connection for bilateral hearing loss. 3. Entitlement to service connection for hypoglycemia. 4. Entitlement to service connection for hemorrhoids. 5. Entitlement to a compensable evaluation for degenerative disc changes of the cervical spine, C5-6, secondary to injury. REPRESENTATION Appellant represented by: AMVETS ATTORNEY FOR THE BOARD Christine E. Puffer, Associate Counsel INTRODUCTION The veteran had active service from November 1967 to November 1991. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 1992 rating decision of the Department of Veterans Affairs (VA) Waco, Texas, Regional Office (RO). In a July 1993 written argument the veteran's representative raised the additional issues of entitlement to service connection for the residuals of an anxiety condition and for aggravation of a heart condition. As neither of these issues has been developed or certified for appellate review, they are referred to the RO for appropriate action. Although the veteran's representative has requested that efforts be expended to obtain the veteran's separation examination report, the veteran has noted that he never underwent one. In this regard, the Board notes that an April 1991 form documented that the veteran voluntarily elected to forgo a retirement physical examination. REMAND Included in the instant appeal is a claim for service connection for hypoglycemia. The veteran reports that he has experienced at least 10 "hypoglycemic reactions" since January 1992. His representative has requested that he also be granted service connection for the aggravation of a heart condition in service and for syncopal episodes. A review of the veteran's service medical records reveals that various evaluations and tests were conducted in service in an effort to determine the cause of his occasional syncopal and dizziness episodes. Possible causes were initially thought to include supraventricular tachycardia that very rapidly self- corrected, paroxysmal atrial tachycardia or paroxysmal supraventricular tachycardia, while near the end of the veteran's 24 years of service examiners suggested other possible causes, including probable vasovagal syncope and consider reactive hypoglycemia. Although an August 1989 consultation report noted a 1/6 systolic heart murmur, an echocardiogram ruled out valvular, atrial or septal defect. The veteran was never diagnosed as suffering from any specific endocrinological, cardiological or neurological condition, and the syncopal episodes were never definitely related to any diagnosis. At the time of an April 1992 VA examination, the veteran was diagnosed, in part, with hypoglycemic reactions. The VA has a duty to assist the veteran in the development of a well-grounded claim. Gilbert v. Derwinski, 1 Vet.App. 49, 55 (1990); 38 U.S.C.A. § 5107(a) (West 1991). The duty to assist includes conducting a thorough and contemporaneous examination of the veteran that takes into account the records of prior medical treatment. Green v. Derwinski, 1 Vet.App. 121 (1991). As the veteran's syncopal and dizziness episodes have never been definitively diagnosed and may be related to some form of hypoglycemic or heart condition, the Board is of the opinion that the duty to assist mandates that these intertwined issues be REMANDED to the RO for a thorough diagnostic examination. Among the veteran's service medical records is a May 1989 surgical consultation report indicating that an anoscopy had revealed evidence of a small internal hemorrhoid. The April 1992 VA evaluation which found no evidence of hemorrhoids appears to have included only an external examination. The veteran continues to complain of bleeding and itching from hemorrhoids. The duty to assist includes obtaining additional examinations when a prior report is found to be inadequate. See Perez v. Derwinski, 2 Vet.App. 562 (1992). The Board finds that a further, more extensive, evaluation is warranted. The Board notes the veteran's representative's request that the issue of service connection for disorders of the entire spine be referred to the RO for development. The Board agrees that such development is warranted in view of the service medical records reflecting cervical spine and chest injuries in l989, and VA examination findings of early facet arthritis in the lumbosacral spine and possible old minimal compression fracture of T5 in January l993, just 13 months after the veteran's retirement from service. Under the circumstances, this case is REMANDED for the following action: 1. The veteran should be afforded special VA examinations to include cardiological, endocrinological and neurological evaluations, to ascertain the etiology, nature and severity of the veteran's syncope and dizziness episodes, including hypoglycemic reaction. It is essential that the examiners thoroughly review the veteran's historical medical evidence in the claims folder prior to rendering any opinion or diagnosis. All indicated tests should be utilized in rendering a complete diagnostic evaluation and in ascertaining the cause of the veteran's syncopal and dizziness episodes. The rationale for all opinions expressed should be stated. 2. The veteran should be afforded a VA gastrointestinal examination to assess the nature and extent of any current hemorrhoids, both internal and external. Any special diagnostic tests, evaluations or studies deemed necessary by the examiner should be conducted. The veteran's claims folder must be made available to the examiner for review prior to, and during, the examination. 3. The veteran should also be afforded a special orthopedic examination for the purpose of determining the nature, severity, and etiology of all disorders involving the entire spine. The examiner should offer an opinion as to the likelihood of a relationship between the findings noted on VA examination dated January l9, l993, and on current examination and the injuries sustained in l989, and the probable time on onset of such disorders. X-rays of the entire spine and any other indicated studies should be completed to facilitate the examiner's assessment. The claims folder must be made available to the examiner for review prior to, and during the examination. When the development requested in the above paragraphs has been completed, the case should again be reviewed on the basis of the additional evidence. The RO should adjudicate the matter of service connection for any disorders involving all spinal segments other than the cervical spine, which is already service connected. Unless the veteran is satisfied with any favorable action and withdraws his appeal, a supplemental statement of the case should be furnished the appellant and his representative. They should then be afforded the appropriate period of time to respond. Thereafter, the case should be returned to the Board for further consideration. The purpose of this REMAND is to assist the veteran in the development of his claim and ensure that he is provided all due process. The Board does not intimate any opinion as to the merits of this case, either favorable or unfavorable, at this time. No action is required of the veteran until he is notified. WARREN W. RICE, JR. 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).