BVA9504851 DOCKET NO. 93-13 438 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Medical and Regional Office Center in Cheyenne, Wyoming THE ISSUES 1. Entitlement to service connection for post-traumatic stress disorder. 2. Entitlement to service connection for a bilateral shoulder disability. ATTORNEY FOR THE BOARD Robert E. O'Brien, Counsel INTRODUCTION The veteran had periods of active service from June 1952 to May 1954 and from July 1957 to August 1975. This case comes before the Board of Veterans' Appeals (Board) on appeal from an October 1992 rating decision of the Department of Veterans Affairs (VA) Medical and Regional Office Center (M&ROC) in Cheyenne, Wyoming. REMAND A review of the evidence of record discloses the veteran had three tours of duty in Vietnam, the first being from December 1965 to December 1966, the second being from May 1968 to May 1969, and the third occurring between May 1971 and May 1972. His medal and badges included the Combat Infantryman Badge, the Army Commendation Medal with "V" Device, and the Meritorious Service Medal. However, at the time of a VA psychiatric examination in July 1992, he denied specific direct contact with frontline combat operations. He did not refer to any specific incident or incidents which he found traumatic, "but generally found the entire operation somewhat difficult to tolerate because he felt he did not have any input or impact on what was being done." The examiner stated that he could not detect "sufficient" components to make a diagnosis of post-traumatic stress disorder. The examiner noted that despite the veteran's significant time in Vietnam, the veteran had difficulty coming up with traumatic elements that could "be in any way" traced to current symptomatology. The Axis I diagnosis was alcohol abuse by history, not currently active. The Axis II diagnosis was a mixed personality disorder with neurotic components. With respect to stressors, the Board notes that the veteran's awards include the Combat Infantryman Badge and that a claimed stressor related to combat may be accepted under 38 C.F.R. § 3.304 (f) (1994). In statements made in May and June 1992, the veteran referred to post-traumatic stress disorder having been detected during hospitalization in 1987 at the Care-Unit Hospital, Kirkland, Washington. Additionally, he stated that he was seen in the psychology service of the VA Medical Center, Seattle, Washington, in 1987 for post-traumatic stress disorder. The only documentation concerning hospitalization at the Care-Unit Hospital in 1987 is a medical discharge summary regarding hospitalization from February to March 1987 for acute and chronic alcoholism. The discharge summary sheet contains no reference to post-traumatic stress disorder, except for a notation that the veteran was planning to attend Vietnam Vet Outreach Counseling. The records regarding the reported evaluation by a clinical psychologist at the VA Medical Center in Seattle are not in the claims folder. With regard to the veteran's claim for service connection for a bilateral shoulder disorder, the Board notes that service connection is currently in effect for osteochondritis dissecans of the right elbow, postoperative status. The veteran claims that he now has a bilateral shoulder disability which cannot be dissociated from the service-connected disorder. The assessment made following VA examination in July 1992 was a history of osteochondritis dissecans with subsequent range of motion limitations and pain in both shoulders and with some radiological evidence suggestive of rotator cuff pathology. There is no specific medical opinion of record as to whether there is a causal relationship between the service-connected right elbow disorder and the development of a bilateral shoulder disability. In light of the foregoing, and the VA's duty to assist the veteran in the development of facts pertinent to his claims, as mandated by 38 U.S.C.A. § 5107(a) (West 1991), the case is REMANDED to the M&ROC for the following actions: 1. The RO should contact the veteran and request that he provide the names and addresses of all health care providers who have treated him for psychiatric symptomatology and shoulder pathology since service discharge and specify the approximate dates of treatment, if possible. Then, after any necessary authorization is obtained from the veteran, the RO should obtain copies of any treatment records identified by the veteran. The Care-Unit Hospital of Kirkland, Kirkland, Washington 98033, should be contacted and asked to provide the complete clinical records pertaining to hospitalization of the veteran from February 2, 1987, to March 2, 1987. The VA Medical Center in Seattle, Washington, should also be contacted and asked to provide complete clinical records pertaining to reported treatment of the veteran at that facility in 1987. 2. Thereafter the M&ROC should arrange for the veteran to be accorded a psychiatric examination to determine the diagnosis or diagnoses of any psychiatric disorder present, including post-traumatic stress disorder. The examination report should reflect review of pertinent material in the claims folder. If the diagnosis of post- traumatic stress disorder is deemed appropriate, the examiner should specify (1) whether each alleged stressor(s) reported is sufficient to produce post- traumatic stress disorder; (2) whether the remaining diagnostic criteria to support the diagnosis of post-traumatic stress disorder have been satisfied; and (3) whether there is a link between the current symptomatology and one or more of the inservice stressors found to be sufficient to produce post-traumatic stress disorder. The report of examination should include the complete rationale for all opinions expressed. All necessary special studies or tests, to include psychological testing and evaluation, such as the Minnesota Multiphasic Personality Inventory, and the Mississippi Scale for Combat-Related Post-Traumatic Stress Disorders, should be accomplished. The entire claims folder and a copy of this REMAND must be made available to the examiner. 3. The veteran should also be accorded an orthopedic examination for the purpose of determining the nature and extent of any bilateral shoulder symptomatology. The examiner should express an opinion as to whether there is a link between any current bilateral shoulder disability and the veteran's service-connected osteochondritis dissecans of the right elbow. All necessary special studies or tests, to include X-ray studies, should be accomplished. The claims folder and a copy of this REMAND must be made available to the examiner. 4. Thereafter, the M&ROC should review the record and ensure that all requested actions are completed. The claims should then be readjudicated. Unless the benefits sought on appeal are granted to the veteran's satisfaction, a supplemental statement of the case should be prepared and he should be given the applicable time period in which to respond. Thereafter, the claim should be returned to the Board for further review if otherwise in order. No action is required of the veteran until he receives further notice. The Board does not intimate any factual or legal conclusions as to any final outcome warranted in the appeal. CHARLES E. HOGEBOOM 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 action has been taken in accordance with the Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 303, 108 Stat. 4645, ___ (1994), and 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).