BVA9506324 DOCKET NO. 93-15 853 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to an increased evaluation for chronic esophagitis secondary to medication for cervical spine degenerative disc disease, currently evaluated as 10 percent disabling. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD L. M. Barnard, Counsel REMAND The veteran served on active duty from December 1975 to May 1978. This appeal arises from a June 1992 rating decision of the St. Petersburg, Florida, Department of Veterans Affairs (VA), Regional Office (RO), which had granted service connection for esophagitis and assigned it a noncompensable evaluation in June 1992. A rating action issued in December 1992, granted a 10 percent disability evaluation for this disability. The veteran contends, in essence, that his service-connected esophagitis is more disabling than the current disability evaluation would suggest. He asserts that he suffers from constant symptoms day and night. He states that he has reflux at all times, and that he cannot take medication for his arthritis because of his esophagitis. Therefore, he believes that a greater disability evaluation is in order. VA has a duty to assist the veteran in the development of all facts pertinent to his claim. 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. § 3.103(a) (1994). This includes the duty to obtain a VA examination which provides an adequate basis upon which to determine entitlement to the benefit sought, as well as the duty to obtain all relevant treatment records. Littke v. Derwinski, 1 Vet.App. 90 (1991). VA has a duty to acknowledge and consider all regulations which are potentially applicable based upon the assertions and issues raised in the record and to explain the reasons used to support the conclusion. Schafrath v. Derwinski, 1 Vet.App. 589 (1991). These regulations include, but are not limited to, 38 C.F.R. § 4.1, that requires that each disability be viewed in relation to its history and that there be an emphasis placed upon the limitation of activity imposed by the disabling condition, and 38 C.F.R. § 4.2 which requires that medical reports be interpreted in light of the whole recorded history, and that each disability must be considered from the point of view of the veteran working or seeking work. These requirements for the evaluation of the complete medical history of the claimant's condition operate to protect claimants against adverse decision based upon a single, incomplete or inaccurate report and to enable VA to make a more precise evaluation of the disability level and any changes in the condition. In the instant case, it is noted that the veteran was last examined by VA in May 1992. This examination did not describe the symptoms from which the veteran suffers, nor did it comment upon the effect that his esophagitis has upon his general health. Therefore, it does not provide an adequate basis upon which to evaluate his claim for an increased evaluation. Furthermore, the record indicates that the veteran has been treated by a private physician for many years. However, the RO has made no attempt to obtain any records that may be relevant in determining entitlement to an increased disability evaluation. Under the circumstances of this case, the undersigned concludes that additional assistance is necessary, and this case is REMANDED to the RO for the following: 1. The RO should contact the veteran and request that he sign and return a consent form authorizing the release of Dr. Mathews' records to VA. Once this consent form is returned, the RO should contact Marion J. Mathews, M. D., The Oaks Medical Center, 425 West 19th Street, Suite A, Panama City, Florida, 32405-4631, and request that he provide copies of the veteran's treatment records developed between May 1992 and the present. 2. Once the above-requested records have been obtained and associated with the claims folder, the RO should afford the veteran a special gastroenterological examination in order to assess the current nature and degree of severity of his service-connected chronic esophagitis. The examination should specifically note whether the veteran experiences dysphagia, pyrosis and regurgitation, with substernal, arm or shoulder pain. The examiner should also describe the effect that the veteran's symptoms have upon his general health. All indicated special studies should be accomplished. The claims folder must be made available to the examiner prior to the examination so that the veteran's entire history can be taken into consideration. In the event that the veteran's claim remains denied, in whole or in part, he and his representative should be provided with an appropriate supplemental statement of the case, and an opportunity to respond, and the case should be returned to the Board for further appellate consideration if otherwise in order. C. P. RUSSELL 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).