BVA9500674 DOCKET NO. 93-06 162 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUES 1. Entitlement to an evaluation in excess of 40 percent for a right below-the-knee amputation. 2. Entitlement to an evaluation in excess of 10 percent for dysthymia. 3. Entitlement to an evaluation in excess of 10 percent for a donor site scar of the right thigh. 4. Entitlement to an evaluation in excess of 10 percent for a donor site scar of the left calf. 5. Entitlement to service connection for a heart disorder, characterized as early repolarization syndrome. 6. Entitlement to a total rating based upon individual unemployability. REPRESENTATION Appellant represented by: Paralyzed Veterans of America, Inc. ATTORNEY FOR THE BOARD J. Johnston, Associate Counsel INTRODUCTION The veteran had active service from May 1973 to May 1975, and from May 1980 to March 1983. This matter comes before the Board of Veterans' Appeals (Board) from an October 1991 rating decision of the Jackson, Mississippi, Department of Veterans Affairs (VA) Regional Office (RO). REMAND The veteran contends that he has early repolarization syndrome, a cardiovascular abnormality, which has resulted from his service- connected right below-the-knee amputation. A history provided by the veteran during his April 1992 VA examination indicated a 10-year history of intermittent hypertension, without medication or treatment and no indication that he has been under the care of a physician for this problem. Blood pressure upon examination was 130/90/80 mm Hg. An electrocardiogram was within normal limits. The diagnosis was a normal cardiovascular examination with American Heart Association Classification 1A. However, the examiner also noted "early repolarization syndrome" but failed to explain the nature of this syndrome and whether it constituted an abnormal finding or disorder, and failed to indicate the etiological origins of the syndrome. Another cardiovascular examination with an explanation of the veteran's heart disorders, if any, is indicated. The representative also requested remand action for this purpose. The veteran claims that he is unable to attain or maintain any substantially gainful employment as a result of service-connected disability. A December 1991 VA mental hygiene clinic report indicates that the veteran was receiving Social Security disability. These records must be obtained for review. Additionally, that entry indicates the veteran has applied for vocational rehabilitation with the VA and a review of the veteran's vocational rehabilitation folder, if in existence, would also be useful in evaluating his claim. It appears that the veteran already has two years of collegiate level education and he may have last worked as a corrections officer in July 1989. Additional development is required prior to final appellate review. The representative also requested remand action for development of this issue. An April 1992 VA psychiatric examination resulted in a diagnosis of dysthymic disorder. However, that examination provided insufficient useful information to quantify the veteran's dysthymic disorder. There was no global assessment of functioning score. The examination also indicated that the veteran was provided a number of cognitive tests which he answered only moderately well. Another VA psychiatric examination is indicated. It should be noted that VA outpatient treatment records from November 1991 indicated the veteran was evaluated by a psychologist via a Beck Depression Inventory and that he received a score placing him in the moderate to severe range of depression. Outpatient treatment records following this evaluation indicate that the veteran was referred on numerous occasions through a "SATP" program and it is unclear from the file whether he attended that program or whether he has continued to receive routine psychological or psychiatric outpatient treatment since that time. A search for additional records must be conducted and another VA psychiatric examination is indicated. The representative has also requested remand action for development of this issue. The VA has a duty to assist the veteran in the development of facts pertinent to his claims. 38 U.S.C.A. § 5107(a) (West 1991). Therefore, the case is REMANDED to the RO for the following: 1. With the veteran's assistance and consent when necessary, the RO should obtain copies of all private and VA treatment records reflecting treatment for any of the veteran's service-connected disabilities or for any heart disorder which are not presently on file. This should include but is not limited to collection of any records of the veteran's treatment for depression or dysthymia or substance abuse. Any private and/or VA medical records which have been created since the file was initially forwarded to the Board should be collected and added to the claims folder. 2. The veteran should be requested to provide a list of all former employers, or employers from whom he has sought, but not obtained full-time or part-time work. Thereafter the firms on the list should be contacted regarding why employment was terminated or why the veteran was not hired, as applicable. 3. The RO is to contact the Social Security Administration and obtain copies of the award letter and all evidence, including medical records, relied upon in support of the award of Social Security disability benefits to the veteran. Once obtained, the information is to be associated with the claims folder. 4. If the veteran has a VA vocational rehabilitation folder, it should be associated with the claims folder for review. 5. Concerning his application for service connection for a heart disorder, characterized as early repolarization syndrome, the veteran should be provided a VA cardiovascular examination. The claims folder should be provided to the examiner for review prior to any examination. All indicated special studies should be performed. The examiner should provide an accurate assessment of cardiovascular abnormalities, if any, and should specifically indicate whether any such abnormalities identified are causally related to the veteran's right below-the-knee amputation. The examiner should review the previous April 1992 VA examination for diseases of the arteries and veins and should explain whether early repolarization syndrome is confirmed and, if so, should explain the nature of that syndrome and whether it constitutes an abnormality or disability as such. 6. The veteran should be afforded a VA psychiatric evaluation by an examiner who has not previously examined or treated him to determine the correct diagnosis of any psychiatric disorders present, the manifestations and symptoms of each, and the impairment resulting from each disorder. All indicated tests and studies, including psychological studies should be performed. The claims folder, a copy of this remand, and all information obtained during the remand should be reviewed by the examiner before rendering any opinion or diagnosis. The examiner should make all appropriate diagnostic findings for Axis I and Axis II psychiatric disorders and should specifically identify the symptoms and manifestations of each disorder. The examiner should also assess the veteran's social and occupational functioning in the context of the Global Assessment of Functioning (GAF) scale, and provide a numerical GAF score on Axis V, (along with the corresponding descriptive phrase) that most appropriately reflects the current severity of the veteran's service-connected psychiatric disability. Finally, the examiner should discuss the effect of dysthymia, if found, on the veteran's ability to pursue any gainful employment in view of his education and work experience. Following completion of the above development, the RO should review the evidence and determine whether the veteran's claims for increased evaluations, for service connection and for a total rating based upon individual unemployability may be allowed. The RO must adjudicate the issue of entitlement to a total rating based upon individual unemployability, to include consideration of 38 C.F.R. § 3.321(b)(1) (1993), if applicable. If any benefit sought on appeal is not allowed, the veteran and his representative should be provided with an appropriate supplemental statement of the case, to include discussion of all issues in appellate status and discussion of 38 C.F.R. § 3.321, and provided a reasonable opportunity to respond. The case should then be returned to the Board for further appellate review. The veteran need do nothing until further notified. RENÉE M. PELLETIER 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) (1993).