Citation Nr: 0000801 Decision Date: 01/11/00 Archive Date: 01/27/00 DOCKET NO. 95-02 702A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for disability manifested by chest pain, other than as a residual of a gunshot wound of the abdomen. 2. Entitlement to service connection for disability manifested by low back pain, other than as a residual of a gunshot wound of the back. 3. Entitlement to an increased initial disability rating for anxiety disorder, currently evaluated as 10 percent disabling. 4. Entitlement to an increased initial disability rating for residuals of a gunshot wound to the abdomen with closed colostomy, currently evaluated as 10 percent disabling. 5. Entitlement to an increased (compensable) initial disability rating for a gunshot wound to the back with retained foreign body. REPRESENTATION Appellant represented by: Military Order of the Purple Heart WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD D. L. Wight, Associate Counsel INTRODUCTION The veteran served on active duty from November 1972 to November 1978 and from May 1979 to May 1993. This case comes before the Board of Veterans' Appeals (Board) by means of 1994 rating decisions rendered by the Atlanta, Georgia, Regional Office (RO) of the Department of Veterans Affairs (VA) wherein service connection for chest pain and low back pain were denied and initial disability ratings were assigned for residuals of gunshot wound to the abdomen, gunshot wound to the back and anxiety reaction. The Board notes that the veteran, on a VA Form 21-4138, Statement in Support of Claim, received in January 1998, appears to raises the issues of entitlement to service connection for asthma and bronchitis as well as increased disability ratings for his ankle disabilities. A review of the claims folder reveals that no decision on these matters has been rendered by the RO. These claims are referred to the RO for further development as appropriate. In November 1999, the veteran submitted additional evidence to the Board, waiving initial consideration of that evidence by the RO. FINDINGS OF FACT 1. Chest pain, other than residuals of service connected gunshot wound, are not shown medically to be a manifestation of chronic disability. 2. The claim for service connection for disability manifested by low back pain is plausible. 3. All evidence necessary for an equitable disposition of the veteran's claims for increased disability ratings has been developed. 4. Prior to August 21, 1998, the veteran's anxiety disorder was manifested by mild occupational and social impairment. Neither definite impairment in the ability to establish or maintain effective and wholesome relations, definite industrial impairment due to reduced initiative, flexibility, efficiency, and reliability; nor occupational and social impairment with occasional decrease in work efficiency; and intermittent periods of inability to perform occupational tasks were shown. 5. From August 21, 1998, the anxiety disorder resulted in occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships 6. Gunshot wound to the abdomen is manifested principally by no more than moderate muscle injury, and post- operative abdominal scarring that is objectively tender and painful. 7. Gunshot wound to the back is manifested principally by objective findings of a small asymptomatic scar, with no functional or objective disability. CONCLUSIONS OF LAW 1. A claim for service connection for disability manifested by chest pain, other than as a residual of a gunshot wound to the abdomen, is not well grounded. 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. §§ 3.303, 3.304 (1999). 2. A claim for service connection for disability manifested by low back pain, other than as a residuals of gunshot wound to the chest, is well grounded. 38 U.S.C.A. § 5107(a) (West 1991). 3. Prior to August 21, 1998, the schedular criteria for a disability rating greater than 10 percent for anxiety disorder were not met. 38 U.S.C. § 1155 (West 1991 & Supp. 1998); 38 C.F.R. Part 4, § 4.130 Diagnostic Code 9400 (1996), (1999); Karnas v. Derwinski, 1 Vet. App. 308, 312-313 (1991). 4. From August 21, 1998, the schedular criteria for a 50 percent disability rating for anxiety disorder are met. 38 U.S.C. § 1155 (West 1991 & Supp. 1998); 38 C.F.R. Part 4, § 4.130 Diagnostic Code 9400 (1996), (1999); Karnas v. Derwinski, 1 Vet. App. 308, 312-313 (1991). 5. The schedular criteria for an increased disability rating of 20 percent for residuals of a gunshot wound to the abdomen with closed colostomy are met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. Part 4, §§ 4.25, 4.56, Diagnostic Codes 5319, 7804 (1999). 6. The schedular criteria for an increased (compensable) disability rating for a gunshot wound to the back with retained foreign body are not met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. Part 4, §§ 4.40, 4.45, 4.56, 4.73, Diagnostic Code 5320 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The threshold question that must be resolved with regard to each claim is whether the veteran has presented evidence that each claim is well grounded; that is, that each claim is plausible. If he has not, the appeal fails as to that claim, and the Board is under no duty to assist him in any further development of that claim, since such development would be futile. 38 U.S.C.A. § 5107(a) (West 1991); Murphy v. Derwinski, 1 Vet. App. 78 (1990). I. Service Connection The law provides that "a person who submits a claim for benefits under a law administered by the Secretary shall have the burden of submitting evidence sufficient to justify a belief by a fair and impartial individual that the claim is well grounded." 38 U.S.C.A. § 5107(a) (West 1991). In order to establish a "well grounded" claim for service connection for a particular disability, the veteran needs to provide evidence relevant to the requirements for service connection and of sufficient weight to make the claim plausible or meritorious on its own and capable of substantiation. Franko v. Brown, 4 Vet.App. 502, 505 (1993); Tirpak v. Derwinski, 2 Vet.App. 609, 610-611 (1992); Murphy v. Derwinski, 1 Vet.App. 78, 81 (1990). The three elements of a "well grounded" claim are: (1) evidence of a current disability as provided by medical diagnosis; (2) evidence of incurrence or aggravation of a disease or injury in service as provided by either lay or medical evidence, as the situation dictates; and, (3) a nexus, or link, between the inservice disease or injury and the current disability as provided by competent medical evidence. Caluza v. Brown, 7 Vet.App. 498, 506 (1995); see also 38 U.S.C.A. § 1110 (West 1991); 38 C.F.R. § 3.303 (1999). The Board notes that service connection may be established for a current disability that has not been clearly shown in service where there is a current disability and a relationship or connection between that disability and a disease contracted or an injury sustained during service is shown. 38 U.S.C.A. § 1110 (West 1991); 38 C.F.R. § 3.303 (1999); Cuevas v. Principi, 3 Vet.App. 542, 548 (1992); Rabideau v. Derwinski, 2 Vet.App. 141, 143 (1992). The Board concludes that medical evidence is needed to lend plausible support for the issues presented by this case because they involve questions of medical fact requiring medical knowledge or training for their resolution. Caluza. See also Layno v. Brown, 6 Vet.App. 465, 470 (1994); Espiritu v. Derwinski, 2 Vet.App. 492, 494-95 (1992). A. Chest Pain The veteran contends that he has disability manifested by chest pain, which he attributes to his active duty service. With regard to this claim for service connection, the determinative issues presented are (1) whether the veteran had an injury or disability to his chest during service; (2) whether he currently has a disability manifested by chest pain; and if so, (3) whether his current chest pain disability is etiologically related to his inservice injury or disability. After a review of the claims folder, the Board finds that the veteran has not submitted evidence sufficient to establish a well-grounded claim for entitlement to service connection for disability manifested by chest pain. Accordingly, his claim fails. The evidence shows that the veteran received a gunshot wound to his abdomen in December 1973. The bullet entered his left chest and exited the right chest through the high upper abdomen. Service medical records indicate he was seen in September 1982 with complaints of persistent left side chest pain gradually increasing in severity. The medical record indicates that the veteran had a prior history of a gunshot wound to the chest. A x-ray was negative and an impression of chest wall pain was noted. Similarly, in September 1990, he was seen with complaints of tenderness and pain in his right breast. An assessment of "muscular ? strain" was rendered. In February 1993, the veteran was afforded a separation examination. The examination report indicates that his lungs, chest, and heart were normal. On a February 1993 report of medical history, the veteran indicated a history of pain or pressure in his chest and palpitation or pounding of his heart. An EKG was within normal limits and a chest x-ray showed a residual metallic foreign body. Post service medical records indicate that the veteran complained of chest pain. An April 1994 VA treatment record indicates that he complained of chest soreness. The treatment record indicates that his heart rate and rhythm were normal without murmurs. A diagnosis of musculoskeletal pain was rendered. Subsequent records of medical evaluation and treatment reflect complaints of chest pain associated with service connected gunshot wound. W hile the veteran has inservice and post- service complaints of chest pain, the medical evidence does not show that these complaints are manifestations of chronic disability other than the service connected gunshot wound to the abdomen. The regulations provide that the evaluation of the same disability under various diagnoses is to be avoided. Disability from injuries to the muscles, nerves, and joints may overlap to a great extent, so that special rules are included in the appropriate bodily system for their evaluation. Both the use of manifestations not resulting from service-connected disease or injury in establishing the service-connected evaluation, and the evaluation of the same manifestation under different diagnoses is to be avoided. 38 C.F.R. § 4.14 (1999). Accordingly, the symptomatology of his musculoskeletal chest pain is properly addressed in connection with an increased disability rating for his gunshot wound of the abdomen. (See discussion below pertaining to a claim for an increased disability rating for residuals of a gunshot wound to the abdomen.) Those complaints of chest pain not due to the gunshot wound were apparently due to acute and transitory musculoskeletal disorders. Since, as previously discussed, these complaints are not due to chronic disability (apart from the already service connected gunshot wounds), the Board must find that the veteran has not submitted evidence sufficient to justify a belief by a fair and impartial individual that his claim is well grounded. 38 U.S.C.A. § 5107(a) (West 1991). See also Tirpak v. Derwinski, 2 Vet. App. 609, 610-11 (1992). The Board accordingly finds that the claim is denied, in accordance with the Court's decision in Edenfield v. Brown, 8 Vet. App. 384 (1995). B. Low Back Disability The veteran contends that he has chronic low back disability manifested by pain, which he attributes to his active duty service. Service medical records show that in August 1975, he complained of continued back pain resulting from an automobile accident in July 1975. An impression of a strained muscle with aggravation to the area near a 1974 gunshot wound was rendered. A December 1981 medical record shows that he complained of back pain while on guard duty. The assessment was possible strain of the back. In May 1992, an assessment of a pulled muscle in the back was rendered. The report of the veteran's retirement examination in February 1993 indicates that his spine and other musculoskeletal system were normal on objective examination. On a February 1993 report of medical history, the veteran indicated that he experienced recurrent back pain. A VA examination report of July 1993 indicates that the veteran had low back pain with no limitation of function. The diagnosis was low back pain, X- rays pending. A July 1993 radiology report indicates that minimal spondylosis was noted as was mild sclerosis at the inferior aspect of the sacroiliac joints bilaterally with osteophyte formation. According to Dorland's Illustrated Medical Dictionary, 26th ed., 1239 (1985), spondylosis is a term for degenerative changes due to osteoarthritis. In a statement in 1994, the veteran reported that he had numbness and tingling radiating into the buttocks and thighs. In a June 1999 statement, Charles A. MacNeill, M.D., reported that he had first seen the veteran in September 1997 for complaints of lower back and bilateral leg pain. Diagnostic studies showed a herniated disc at L4-5. The Board finds that the claim for service connection for a low back disability is plausible. Service medical records show low back symptomatology secondary to injury (other than the gunshot wound), and the post-service medical records show some form of chronic low back disability associated with degenerative within one year of service separation. (See 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137 (West 1991); 38 C.F.R. §§ 3.307, 3.309 (1999), pertaining to presumptive service connection for osteoarthritis.) Subsequent medical evidence shows a diagnosis of herniated disc L4-5. This disorder or disorders of the low back are separate and distinct from the service connected gunshot wound. The Board concedes that a chronic low back disability, as yet undiagnosed, but associated with arthritis, was present within a year of service separation. This renders the claim plausible, triggering VA's duty to assist the veteran. This matter is addressed in the remand appended to this decision. II. Increased Disability Ratings Generally, claims for increased evaluations are considered to be well grounded. A claim that a condition has become more severe is well grounded where the condition was previously service connected and rated, and the claimant subsequently asserts that a higher rating is justified due to an increase in severity since the original rating. Proscelle v. Derwinski, 2 Vet.App. 629, 632 (1992). Accordingly, the Board finds that the veteran's claims for increased disability ratings are "well grounded" within the meaning of 38 U.S.C.A. § 5107(a) (West 1991); that is, he has presented claims that are plausible. He has not alleged that any records of probative value that may be obtained and which have not already been associated with his claims folder are available. The Board accordingly finds that the duty to assist him, as mandated by 38 U.S.C.A. § 5107(a) (West 1991), has been satisfied. Disability evaluations are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4 (1999). The percentage ratings in the Schedule for Rating Disabilities represent, as far as can practicably be determined, the average impairment in earning capacity resulting from such disabilities and their residual conditions in civil occupations. 38 C.F.R. § 4.1 (1999). Moreover, each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2 (1999). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (1999). The terms "mild," "moderate," and "severe" are not defined in the Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6 (1999). It should also be noted that use of terminology such as "mild" or "moderate" by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6 (1999). A. Anxiety Reaction Service connection for anxiety was established by means of a February 1994 rating action as service medical records indicate that the veteran had anxiety while on active duty. A 10 percent disability rating was assigned effective June 1, 1993, the day after the veteran separated from active duty. By means of a December 1994 rating action, the RO denied an increased disability evaluation for the veteran's anxiety. The veteran appeals this rating action and contends that his anxiety is more severe than currently evaluated and that an increased disability rating is warranted. The veteran's current anxiety disorder is currently evaluated under Diagnostic Code 9400. 38 C.F.R. § 4.130 (1999). Under these criteria, a 10 percent disability rating contemplates occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress; or symptoms controlled by continuous medication. A 30 percent disability rating contemplates occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). A 50 percent evaluation is appropriate for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted for occupational and social impairment with deficiencies in most areas such as work, family relations, judgment, thinking, or mood, due to such items as: suicidal ideation; obsessional rituals which interfere with routine activity; speech intermittently illogical, obscure or irrelevant; near- continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances and inability to establish and maintain effective relationships. A 100 percent evaluation is warranted where there is total occupational and social impairment, due to symptoms such as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation or name. The criteria for evaluation of mental disorders were amended during the pendency of the veteran's appeal, effective November 7, 1996. See 61 Fed. Reg. 52,700 (October 8, 1996). Pursuant to the criteria in effect prior to November 7, 1996, the General Formula for Rating Psychoneurotic Disorders provided that a 10 percent rating was warranted with emotional tension or other evidence of anxiety productive of mild social and industrial impairment. A 30 percent rating was warranted where the evidence showed definite impairment in the ability to establish or maintain effective and wholesome relationships with people; the psychoneurotic symptoms resulted in such reduction in initiative, flexibility, efficiency, and reliability levels as to produce definite industrial impairment. A 50 percent rating was warranted where the evidence showed that the ability to establish or maintain effective or favorable relationships with people was considerably impaired; by reason of psychoneurotic symptoms the reliability, flexibility, and efficiency levels were so reduced as to result in considerable industrial impairment. A 70 percent evaluation required that the ability to maintain effectively or favorable relationships with people was severely impaired, with psychoneurotic symptoms of such severity and persistence that there was severe impairment in the ability to obtain or retain employment. A 100 percent evaluation was warranted where the attitudes of all contacts except the most intimate were so adversely affected as to result in virtual isolation in the community. Totally incapacitating psychoneurotic symptoms bordering on gross repudiation of reality with disturbed thought or behavioral processes associated with almost all daily activities such as fantasy, confusion, panic and explosions of aggressive energy resulting in profound retreat from reality. Demonstrably unable to obtain or retain employment.38 C.F.R. § 4.132, Diagnostic Code 9400 (1996). On VA psychiatric examination in July 1993, the veteran described what were characterized by the examiner as mild psychiatric problems. The diagnoses included mild anxiety reaction with history of mild insomnia and mild headaches. An August 1994 VA medical certificate contains a social work note that indicates that the veteran was seeking medication for his anxiety. He denied any suicidal or homicidal ideations and indicated that he was attending school and worked at a VARO. He was noted to be alert, cooperative, oriented, and neatly groomed. A VA mental health clinic (MHC) record from August 1994 indicates that the veteran had anxiety manifested by nervousness, sweaty palms and uncomfortability in large crowds. The record also indicates that the veteran had a startle response and that he did not get out much as he preferred to stays home. A diagnosis of mild to moderate PTSD (post-traumatic stress disorder) was rendered. A November 1994 mental health center treatment record indicates that the veteran's medicine was helping his symptoms and had no side effects. The record indicates that he felt as though he was in control. At a personal hearing before a RO hearing officer in February 1995, the veteran indicated that he was able to keep a "low profile" that "no one really knows that [he has] a nervous condition." He indicated that he sometimes will lose his train of thought. He indicated that he sometimes will become extremely nervous while talking with someone and cannot carry on a conversation. He indicated that, while he prefers to work alone, he has had no difficulties with fellow employees or with his supervisors. He stated that he had "no problem getting along with people that [he could] see." He stated that his thirteen-year marriage had ended in divorce in July 1994; however, he indicated that his nervous condition did not break up the marriage. He admitted to nightmares about the 1973 and 1974 shootings and that he has a startle reaction to loud noises such as cars backfiring. He stated that he lives with his mother and that they get alone well together. A February 1996 VA mental examination report indicates that the veteran was neatly dressed in a military uniform. He was noted to be somewhat depressed. He answered questions in a soft, slow, deliberate tone. He indicated that he had trouble getting alone with people and did not trust anyone. The report indicates that the veteran stated that he maintained a close relationship with his children even though they did not live together. The report indicates that he had two jobs: a file clerk at the RO and a job at the Cobb County Detention Center on weekends. The examiner noted that the veteran's thought processes were normal and there were no delusional or hallucinatory elements. His mood was depressed and his sensorium was intact. A February 1996 MHC treatment record indicates that the veteran had thoughts about the person who shot him but did not intend to injure him. The record further indicates that he veteran had not sought treatment at the MHC in months and had been off his medication. He was recently placed back on medication that reduced his tension and improved his sleep. A May 1996 MHC outpatient treatment record indicates that the veteran was completely focused on a lawsuit against the man who shot him. He answered questions about his emotional symptoms in legal terms. He complained of poor sleep and startle reactions. The record indicates that the veteran drank 3 or 4 beers daily. It was recommended that he decrease his drinking. He was to return to the clinic in four months. On August 21, 1998 the veteran was afforded psychiatric examination for VA. The examination report indicates subjective complaints of flashbacks of the inservice "shootings," social withdrawal, impaired memory and concentration, depressed mood, irritability, decreased libido, anxiousness, anhedonia, homicidal ideation toward the men who shot him, crying spells, and panic symptoms. He reported that his panic symptoms, including increased heart rate, sweating, shortness of breath, and paresthesia occur weekly. He reported nightmares and flashbacks two to three times a month. The report indicated that the veteran was not under the care of a psychiatrist, but was receiving medication from his private medical doctor. He denied any current alcohol or marijuana abuse. The veteran reported that he missed time from work due to medical appointments. While he indicated that he avoided people at work due to anxiety, the veteran had maintained employment at the VA for four years prior to the examination. The veteran reported that he had no friends and spent his time "looking at TV." Objectively, the veteran was alert and casually and neatly dressed. His speech was very circumstantial and his affect was constricted with irritable, angry and depressed mood. He was tearful during the interview. The examiner noted that he was preoccupied with being shot and not receiving compensation. While he was only able to name one out of three objects after 5 minutes and was unable to do serial 7's, he was oriented to person, place, month and year. His judgment was fair and he denied auditory or visual hallucinations, delusions, paranoid ideations, or suicidal ideations. He admitted to homicidal ideations toward the men who had shot him. He denied obsessions or compulsions. The diagnoses included generalized anxiety disorder and depressive disorder. The overall Global Assessment of Functioning score (GAF) was 51. Prior to the psychiatric examination conducted for VA on August 21, 1998, the Board finds that the criteria for an increased disability rating under either the old or new criteria is not warranted. During this time period, the psychiatric assessment was of mild disability, while manifestations of the psychiatric disability consisted principally of depressed mood, tension and mild insomnia and headaches. The veteran held two jobs, testified that he had not had any problems with either his superiors or fellow employees, and reported that he got along well with certain family members. Accordingly, after a review of the evidence, the Board finds that prior to August 21, 1998, he did not have definite impairment in the ability to establish and maintain relationships or definite industrial impairment. The Board also finds that an increased rating under the criteria currently in effect is also not warranted because the evidence did not show that the veteran's psychiatric disability had resulted in intermittent periods of inability to perform his occupational tasks. The Board, however, does find that as of the psychiatric examination for VA on August 21, 1998, the veteran met the criteria for a 50 percent rating under the new criteria. That is, the evidence showed that psychiatric disability caused occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; weekly panic attacks; circumstantial speech; impaired memory; impaired judgment; disturbances of mood; and difficulty in establishing and maintaining effective relationships. Further, the psychiatric assessment of his psychological, social and occupational functioning on that date, as measured by the GAF score, was moderate symptoms or moderate difficulty in social and occupational functioning. This evidence is consistent with a 50 percent rating under the new criteria. It is not consistent the assignment of a higher rating under the old or the new criteria because the veteran did not show severe social or industrial impairment or occupational and social impairment with deficiencies in most areas such as work, family relations, judgment, thinking, or mood, due to such items as: suicidal ideation; obsessional rituals which interfere with routine activity; speech intermittently illogical, obscure or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances and inability to establish and maintain effective relationships due to psychoneurosis. B. Gunshot Wound to the Abdomen Service connection for a gunshot wound to the abdomen, status post operative colostomy, was established by means of a June 1994 rating action. Service medical records indicated that the veteran sustained a through and through gunshot wound that entered the left side of his chest and exited through the right side of his chest through the high upper abdomen. As result of this gunshot wound, the veteran underwent abdominal surgery resulting in a colostomy. A 10 percent disability rating was assigned effective June 1, 1993, the day after the veteran separated from active duty as the evidence showed a through and through gunshot wound. 38 C.F.R. § 4.56. The veteran appeals this rating action and claims that his gunshot wound to the abdomen is more severe than currently evaluated and that an increased disability rating is warranted. The veteran's residuals of a gunshot wound to the abdomen are currently evaluated under Diagnostic Code 5319. Under these criteria, a 10 percent disability rating contemplates moderate disability of muscle group XIX. A 30 percent disability rating contemplates moderately severe disability of muscle group XIX. Diagnostic Code 5319 indicates that this muscle group provides support and compression of the abdominal wall and lower thorax; flexion and lateral motions of the spine; and synergists in strong downward movements of the arm. 38 C.F.R. § 4.73 (1999). Additionally, a through- and-through injury with muscle damage shall be evaluated as no less than a moderate injury for each group of muscles damaged. 38 C.F.R. § 4.56 (b) (1999). The veteran underwent VA examination in March 1995, at which time he reported a history of negative colonoscopy in 1992. Findings included chest and abdominal scars, well- healed, noninfected and non- tender. Bowel sounds were present. The examiner commented that the midline abdominal scar "should not involve any muscle group." The lateral abdominal scar "may involve anterior abdominal wall muscles. Objectively, these muscles are intact and normal." In 1997, the veteran underwent wound exploration at the colostomy site because of history of pain. In July 1997, prior to surgery, Daniel Tookes, M.D., reported that there was some nodularity and slight tenderness in the area. No hernia was found. A June 1998 medical examination for VA indicates that that the veteran had a 2 cm entrance wound in the left chest with an exit wound of 1.5 cm on the right side. He also had a 3 cm long surgical scar from a chest tube placement. There was a 23 cm long midline abdominal scar and a horizontal abdominal scar in the left epigastrium that was 12 cm in length. The entrance wound was not tender. There did not seem to be any major underlying tissue loss or any disfigurement. Similarly there was no ulceration or breakdown. The exit wound was noted to have symptomatology as did the entrance wound. With respect to the chest tube wound, the examination report indicates that there was no tenderness and no adherence. The texture of the wound was soft with a slight depression; however, no evidence of underlying tissue loss or major disfigurement was presented. Similarly, there was no limitation of function with respect to the scarring. The examination report indicates no evidence of inflammation, edema, or keloid formation and no evidence of any burns at all on the veteran. With respect to the abdominal scarring, the veteran complained of tenderness to palpation; however, there was no evidence of adherence and the texture was soft. There was similarly no evidence of major underlying tissue loss and no major disfigurement with no ascertainable limitation of function. The examiner noted that there may be mild keloid formation of the abdominal scar. The veteran reported abdominal pain from the scar that the veteran said limited his ability to move about and sit up. In his December 1995 RO hearing, the veteran indicated that he had a "muscle bulge" in his abdomen; however, his private medical doctor in June 1998 indicated that he could not objectively confirm the presence of such symptomatology. The examiner indicated that he was unable to find "any evidence of muscle bulges or herniation of any viscera or anything on the abdomen." The examiner noted that the veteran's abdominal wall muscles were intact and normal. In August 1999, William Fortson, M.D., reported that he had examined the veteran in August that year for pain at the colostomy site. A sonogram of the abdomen was normal, with no evidence of herniation. He was referred to a pain clinic for further treatment of pain at the colostomy site. Based on the evidence as set forth above, the Board finds that the criteria for an increased rating for residuals of a gunshot wound under Diagnostic Code 5319 are not met. The evidence does not show moderately severe disability of the involved abdominal muscles. Pursuant to the regulations, moderately severe disability of the muscles involves through and through or deep penetrating wound by a small high velocity missile or large low-velocity missile, with intermuscular scarring and debridement, prolonged infection, or sloughing of soft parts. Objective findings of moderately severe muscle disability include entrance and (if present) exit scars indicating track of missile through one or more muscle groups. Indications on palpation of loss of deep fascia, muscle substance, or normal firm resistance of muscles compared with sound side. Tests of strength and endurance compared with sound side demonstrate positive evidence of impairment. 38 C.F.R. § 4.56 (d) (3) (1999). While there is some evidence of mild keloid formation involving the abdominal scar, there is no indicated of underlying muscle loss. Similarly, the examiner noted that the range of motion of all affected joints with the exception of the hips was within normal limits. In brief, the preponderance of the evidence is against the veteran's claim for an increased rating for a gunshot wound to the abdomen under Diagnostic Code 5319 disability as the diagnostic criteria are not satisfied. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. Part 4, §§ 4.40, 4.45, 4.56, 4.73, Diagnostic Code 5319 (1999). While an increased rating under Diagnostic Code 5319 is not warranted, the Board notes that the United States Court of Veterans Appeals (Court) has held that scarring, such as that resulting from surgery, can be rated, for VA benefits purposes, as separate and distinct from underlying symptomatology. Esteban v. Brown, 6 Vet.App. 259 (1994). Diagnostic Code 7803 allows a 10 percent disability rating for superficial scars that are shown to be poorly nourished and which manifest repeated ulceration. Diagnostic Code 7804 allows a 10 percent disability rating for superficial scars that are noted to be tender and painful on objective demonstration. 38 C.F.R. § 4.118 (1999). The June 1998 examination report indicates that the veteran's abdominal scarring was tender on palpation. There is other medical evidence that he had pain associated with the scar. Accordingly, the Board finds that an additional 10 percent disability rating for the abdominal scarring is warranted under Diagnostic Code 7804. However, no further additional compensation is warranted under the other diagnostic codes for rating scars. Although the veteran claimed limitation on function due to the scar, no associated limitation on function has been shown medically. Accordingly, a separate compensable rating under Diagnostic Code 7803 is not warranted. In summary, residuals of the gunshot wound to the abdomen warrant a combined 20 percent rating. 38 C.F.R. § 4.25. C. Gunshot Wound to the Back Service medical records indicate that the veteran sustained a small caliber gunshot wound to the paravertebral muscles of the left back in August 1974 while on active duty. Service medical records indicate that the bullet remained intact posterior to the lamina of approximately T4 on the left and was not adjacent to bone. A noncompensable disability rating was assigned effective June 1, 1993, the day after the veteran separated from active duty. The veteran appeals this rating action and claims that his residual of a gunshot wound to the back is more severe than currently evaluated and that an increased disability rating is warranted. The veteran's current gunshot wound to the back is currently evaluated under Diagnostic Code 5320. Under this criteria a noncompensable disability rating contemplates slight limitation of function of the cervical and thoracic region of muscle group XX. A 10 percent disability evaluation is appropriate for moderate limitation of function of muscle group XX. Diagnostic Code 5320 indicates that muscle group XX functions in the postural support of the body and extension and lateral movements of the spine. In order to establish a moderate level of disability, there must be objective findings of some loss of deep fascia or muscle tonus and loss of power or lowered threshold of fatigue when compared to the sound side. 38 C.F.R. § 4.56 (d) (2) (1999). Post VA service medical records indicate that the veteran was seen in August 1994 with complaints of back spasms attributed to the gunshot wound to the back. He was given Ibuprofen and referred to the mental health clinic for evaluation. A March 1995 VA examination report indicates that there was a 4 mm diameter, circular scar possibly related to the 1974 gunshot injury. The report indicates that the scar was well- healed, noninfected, and nontender. It was medial to and slightly inferior to the left scapula. The report further indicates that the scar was "very hard to distinguish from minor injuries." The muscle groups involved were probably the intercostal muscles on both sides of the lateral chest wall, without any functional or objective disability. A March 1995 x-ray report indicates retained metallic fragments with the largest fragment noted to be closely related to one of the mid thoracic vertebrae with a diameter of 1.2 cm, the other fragments are noted to be "much smaller in size." A September 1997 private medical record indicates that the veteran was seen with complaints of lower back pain with bilateral leg pain and chronic anxiety. The symptomatology was assessed as probable neuropathic pain of an unknown etiology, most likely related to his anxiety state. In brief, the preponderance of the evidence is against the veteran's claim for a compensable rating for residuals of a gunshot wound to the back, as the diagnostic criteria for an increased rating for this disability are not satisfied. The evidence does not show objective findings of some loss of deep fascia or muscle tonus and loss of power or lowered threshold of fatigue when compared to the sound side. In fact, the recent evidence shows no functional or objective disability associated with the gunshot wound. While the veteran complains of back pain, the preponderance of the objective evidence shows that his back pain is not related to the gunshot wound, but to other disability. Accordingly, the Board finds that an increased disability rating under Diagnostic Code 5320 is not warranted. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. Part 4, §§ 4.40, 4.41, 4.56, 4.73, Diagnostic Code 5320 (1999). The Board notes that the United States Court of Veterans Appeals (Court) has held that scarring, such as that resulting from surgery, can be rated, for VA benefits purposes, as separate and distinct from underlying symptomatology. Esteban v. Brown, 6 Vet.App. 259 (1994). Diagnostic Code 7803 allows a 10 percent disability rating for superficial scars that are shown to be poorly nourished and which manifest repeated ulceration. Diagnostic Code 7804 allows a 10 percent disability rating for superficial scars that are noted to be tender and painful on objective demonstration. 38 C.F.R. § 4.118 (1999). However, the evidence, as set forth above, does not show that the veteran has a poorly nourished and repeatedly ulcerating scar, nor does the evidence show a tender and painful scar. Accordingly, a compensable disability rating under Diagnostic Codes 7803 and 7804 is not warranted. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. Part 4, § 4.118, Diagnostic Codes 7803, 7804 (1999). ORDER Service connection for disability manifested by chest pain, other than as a residual of a gunshot wound of the abdomen, is denied. The claim for service connection disability manifested by low back pain, other than as a residual of gunshot wound, is well grounded. To this extent only, the claim is allowed. Prior to August 21, 1998, an increased disability rating for anxiety disorder is denied. From August 21, 1998, an increased rating to 50 percent for anxiety disorder is granted, subject to the criteria that govern the payment of monetary awards. An increased disability rating to 20 percent for residuals of a gunshot wound to the abdomen with closed colostomy is granted, subject to the laws and regulations governing the award of monetary benefits. An increased rating for residuals of a gunshot wound to the back is denied. REMAND Because the claim of entitlement to service connection for low back disability, as yet undiagnosed, but associated with arthritis, is well grounded, VA has a duty to assist the veteran in developing facts pertinent to the claim. 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. § 3.159 (1999); Murphy v. Derwinski, 1 Vet. App. 78 (1990). Prior to VA examination to determine the nature and etiology of low back disability or disabilities, the veteran should submit all records pertaining to treatment of the low back since service that are not already associated with the claims file. The claim is REMANDED for the following: 1. The RO should take the necessary steps to obtain all records of the veteran's post- service treatment for the low back, to include records from Dr. Davis Apple, and associate those records with the file. 2. The RO should then schedule the veteran for VA examination by an orthopedic specialist to determine the diagnosis and etiology of all low back disorders. Any indicated diagnostic tests should be performed. Following examination, the examiner should answer the following questions: (1) What are the current diagnoses pertaining to the low back; (2) What was the diagnosis of the low back disability shown on VA X - rays in July 1993; and (3) Does the recently diagnosed herniated disc, L4-5, or other chronic low back disability, represent a progression of the disability shown within a year of service, or is it part and parcel of that disability? The rationale for the opinions should be set forth. 3. The RO should then adjudicate the merits of the claim. If the benefits sought are not granted, the case should be returned to the Board after completion of the usual adjudication procedures. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded to the regional office. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment by the RO. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See The Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 302, 108 Stat. 4645, 4658 (1994), 38 U.S.C.A. § 5101 (West Supp. 1999) (Historical and Statutory Notes). In addition, VBA's Adjudication Procedure Manual, M21-1, Part IV, directs the ROs to provide expeditious handling of all cases that have been remanded by the Board and the Court. See M21-1, Part IV, paras. 8.44- 8.45 and 38.02-38.03. NANCY I. PHILLIPS Member, Board of Veterans' Appeals