BVA9501190 DOCKET NO. 93-04 197 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUE Restoration of a 30 percent disability evaluation for Crohn's disease. ATTORNEY FOR THE BOARD Melissa F. Marquez, Associate Counsel INTRODUCTION The appellant had active service from August 1967 to December 1988. This matter came before the Board of Veterans' Appeals (hereinafter Board) on appeal from the rating decisions of May and August, 1992, of the Chicago, Illinois, Regional Office (hereinafter RO), of the Department of Veterans Affairs (hereinafter VA), which in part, reduced the evaluation for the appellant's service connected Crohn's disease from 30 to 10 percent. REMAND Service medical records reveal that the appellant was diagnosed with Crohn's disease in 1982, which remained essentially asymptomatic until 1987. The record further reflects that the appellant was treated for numerous intestinal and digestional symptomatology from 1987 to 1988. As a result, he underwent the surgical removal of eight inches of his small intestine and eight inches of his colon, including the cecal valve, in September 1988; as well as two colonoscopies dated in April and December 1988. In addition, the record reflects the appellant underwent a 1979 anal fissurectomy. By a rating decision dated in April 1989, service connection for Crohn's disease, status post resection eight inches terminal ilium and eight inches ascending colon with colostomy, was granted, with a 30 percent disability evaluation assigned. Relevant post-service medical reports of record include VA examinations dated in January 1989 and April 1992. However, the appellant has stated in his Notice of Disagreement, as well as in his substantive appeal, that he has received treatment from a service department facility since 1989 for Crohn's disease, including approximately 22 visits to the emergency room and two hospitalizations. He further stated that such related symptomatology resulted in absenteeism from his employment approximately 65 days in the last year. The Board has a duty to assist the appellant in the development of facts pertinent to his claim. 38 U.S.C.A. § 5107(a) (West 1991). This duty includes obtaining medical records and examinations relevant to the issue on appeal. See Murphy v. Derwinski, 1 Vet.App. 78 (1990); Littke v. Derwinski, 1 Vet.App. 90 (1990); Schafrath v. Derwinski, 1 Vet.App. 589 (1991). There are no aforementioned post-service medical reports currently associated with the claims folder, nor is there any indication that the RO has attempted to obtain them. Furthermore, there are no employment records associated with the claims folder. Finally, the April 1992 VA examination was reportedly based solely upon a limited medical history provided by the appellant on the day of such exam, as the claims folder was unavailable at that time for review by the examiner. This was deemed significant by the examiner as the veteran was reported to be a poor historian. An adequate examination, in most cases, requires that a disability be viewed in relation to its whole history. See 38 C.F.R. § 4.1 (1993); Schafrath v. Derwinski, 1 Vet.App. 589 (1991); Tucker v. Derwinski, 2 Vet.App. 201 (1992). Therefore, the Board concludes that a recent VA examination based upon a complete documented medical history is necessary for an adequate evaluation of the appellant's service connected Crohn's disease. Accordingly, the case is REMANDED for the following developments: 1. The RO should contact the appellant to determine the names, addresses, and dates of treatment of any physicians, hospitals or treatment centers (private, VA or military) who provided him with relevant post-service treatment for Crohn's disease, including but not limited to treatment in the emergency room, any inpatient or outpatient care, at Scott Air Force Base, Illinois. After obtaining the appropriate signed authorization for release of information forms from the appellant, the RO should contact each physician, hospital, or treatment center specified by the appellant to obtain any and all medical or treatment records or reports relevant to the above mentioned claim. All pieces of correspondence, as well as any medical or treatment records obtained, should be made a part of the claims folder. If private treatment is reported and those records are not obtained, the appellant and his representative should be provided with information concerning the negative results, and afforded an opportunity to obtain the records. 38 C.F.R. § 3.159 (1993). 2. The RO should contact the appellant to obtain the name and address of his employer or employers since 1992. After obtaining the appropriate signed authorization for release of information forms from the appellant, the RO should contact each employer named by the appellant and request copies of personnel records indicating amounts of sick and/or annual leave used, and reasons therefore, if available, as well as any medical examinations or treatment performed on behalf of such employer. All correspondence, as well as any records receive, should be associated with the claims folder. 3. The RO should schedule the appellant for a complete examination in order to determine the current severity of Crohn's disease. All indicated tests and studies should be done, and all subjective complaints and objective findings should be reported in detail. The claims folder and the records received pursuant to the above paragraphs should be made available to the examiner prior to the examination, and the examiner is requested to provide a detailed medical history of the appellant's service- connected Crohn's disease during said examination. It should also be specifically noted whether the objective data, including laboratory studies reveal any indications of anemia. The examination should be conducted and reported in accordance with the guidelines set forth in the VA Physician's Guide for Disability Evaluation Examinations. 4. The RO should then readjudicate the appellant's claim for restoration of the 30 percent rating for Crohn's disease with application of the appropriate diagnostic codes in the Schedule for Rating Disabilities to determine the percentage of impairment caused by such disability. In order to avoid undue delay in this case, the RO should make certain that the instructions contained in the REMAND decision, detailing the requested developments, have, in fact, been substantially complied with. When these developments has been completed, and if the benefit sought is not granted, the case should be returned to the Board for further appellate consideration, after compliance with appropriate appellate procedures, including issuance of a supplemental statement of the case. It is requested that this statement specifically set forth the reasons and bases for the decision. No action by the appellant is required until he receives further notice. The Board intimates no opinion, either legal or factual, as to the ultimate disposition warranted in this case, pending completion of the requested development. MICHAEL D. LYON 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).