Citation Nr: 0200023 Decision Date: 01/02/02 Archive Date: 01/11/02 DOCKET NO. 97-03 869 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to service connection for a chronic skin disorder to include a rash claimed as the result of Agent Orange exposure. 2. Entitlement to service connection for post-traumatic stress disorder. 3. Entitlement to service connection for a chronic ulcer disorder claimed as the result of Agent Orange exposure. 4. Entitlement to service connection for a chronic prostate disorder claimed as the result of Agent Orange exposure. 5. Entitlement to service connection for a left wrist disorder to include a cyst claimed as the result of Agent Orange exposure. 6. Entitlement to service connection for a chest disorder to include a cyst claimed as the result of Agent Orange exposure. 7. Entitlement to service connection for an eye disorder claimed as the result of Agent Orange exposure. 8. Entitlement to service connection for blackouts claimed as the result of Agent Orange exposure. 9. Entitlement to service connection for stiff-man syndrome claimed as the result of Agent Orange exposure. 10. Entitlement to service connection for gout claimed as the result of Agent Orange exposure. 11. Entitlement to service connection for a hernia claimed as the result of Agent Orange exposure. 12. Entitlement to service connection for hypertension claimed as the result of Agent Orange exposure. 13. Entitlement to service connection for chronic sleep disorder. 14. Entitlement to a disability evaluation in excess of 10 percent for the veteran's anxiety reaction to include the issue of whether the May 1996 reduction of the evaluation for that disability from 50 to 10 percent was proper. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARINGS ON APPEAL The veteran ATTORNEY FOR THE BOARD J. T. Hutcheson, Counsel INTRODUCTION The veteran had active service from November 1966 to October 1968. In March 1996, the Columbia, South Carolina, Regional Office (RO) proposed to reduce the disability evaluation for the veteran's service-connected anxiety reaction from 50 percent to noncompensable due to the veteran's failure to report for a scheduled Department of Veterans Affairs (VA) examination for compensation purposes. This matter came before the Board of Veterans' Appeals (Board) on appeal from a May 1996 RO decision which, in pertinent part, reduced the evaluation for the veteran's anxiety reaction from 50 percent to 10 percent as of August 1, 1996 and denied service connection for post-traumatic stress disorder (PTSD). In December 1996, the RO denied service connection for a chronic skin disorder to include a rash, a chronic ulcer disorder, a chronic prostate disorder, a left wrist disorder to include a cyst, a chest disorder to include a cyst, an eye disorder, blackouts, stiff-man syndrome, gout, a hernia, hypertension, and a chronic sleep disorder claimed as the result of Agent Orange exposure. In December 2000, the veteran was afforded a hearing before the undersigned Member of the Board sitting at the RO. The veteran has been represented throughout this appeal by the American Legion. FINDING OF FACT The veteran manifested chronic dermatitis during active service and following service separation. CONCLUSION OF LAW Chronic dermatitis was incurred during wartime service. 38 U.S.C.A. §§ 1155, 5107 (West 1991 & Supp. 2001); 38 C.F.R. § 3.303 (2001). REASONS AND BASES FOR FINDINGS AND CONCLUSION In reviewing the issue of service connection for a chronic skin disorder, the Board observes that the VA has secured or attempted to secure all relevant VA and private medical records to the extent possible. There remains no issue as to the substantial completeness of the veteran's claim. Veterans Claims Assistance Act of 2000, Pub. L. No. 106-475, 114 Stat. 2096 (2000) (VCAA). The veteran has been advised by the statement of the case and the supplemental statements of the case of the evidence that would be necessary for him to substantiate his claim. The veteran was afforded hearings before both VA hearing officers and the undersigned Member of the Board. The hearing transcripts are of record. Any duty imposed by VCAA, including the duty to assist and to provide notification, has been met. Service connection may be granted for chronic disability arising from disease or injury incurred in or aggravated by wartime service. 38 U.S.C.A. § 1110 (West 1991 & Supp. 2001). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b) (2001). The veteran's service medical records reflect that he was treated for skin complaints on several occasions. Treatment entries dated in October 1967 convey that the veteran exhibited patches of lichenified skin on his neck. An impression of questionable lichen planus was advanced. A November 1967 biopsy evaluation revealed non-specific chronic dermatitis. A June 1968 treatment entry states that the veteran exhibited a licheniform lesion on his neck. The veteran's history of chronic non-specific dermatitis was noted. A September 1968 treatment entry reflects that the veteran had a reoccurrence of dermatitis on his neck. An August 1981 VA hospital summary states that the veteran was diagnosed with atopic dermatitis. A February 1985 VA treatment record reports that the veteran presented a history of a scaly skin rash of nineteen years' duration. The veteran was diagnosed with tinea corporis. An April 1985 VA treatment record indicates that the veteran was diagnosed with nummular eczema. VA clinical documentation dated in July, August, and September 1985 indicates that the veteran presented a fifteen-year history of atopic dermatitis or eczema. Treating VA medical personnel advanced impressions of dermatitis, atopic dermatitis, and eczema. A September 1993 VA treatment record states that the veteran complained of a chronic rash of twenty years' duration. A diagnostic impression of eczema was advanced. A February 1994 VA treatment record reflects that the veteran was again diagnosed with atopic dermatitis. A September 1995 VA treatment record notes that the veteran complained of a chronic rash. An April 1997 VA hospital summary reports that the veteran was diagnosed with eczema. At a May 2000 VA examination for compensation purposes, the veteran reported that he had eczema for which he used a prescribed ointment. The veteran was diagnosed with chronic eczema and dermatitis. The Board has reviewed the probative evidence of record including the veteran's testimony and statements on appeal. The veteran was diagnosed with chronic dermatitis during active service and at the most recent VA examination for compensation purposes of record. In view of the continuity of the veteran's symptomatology and given the absence of any evidence to the contrary, the Board concludes that service connection is now warranted for chronic dermatitis. ORDER Service connection for chronic dermatitis is granted. REMAND The veteran asserts that service connection is warranted for PTSD, a chronic ulcer disorder, a chronic prostate disorder, a left wrist disorder to include a cyst, a chest disorder to include a cyst, an eye disorder, blackouts, stiff-man syndrome, gout, a hernia, hypertension, and a chronic sleep disorder and the record supports restoration of a 50 percent evaluation for his service-connected anxiety reaction. He contends that: PTSD was precipitated by his Vietnam combat experiences; the other claimed disabilities were manifested secondary to Agent Orange exposure; and his anxiety reaction has not improved. Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a) (2001); a link, established by medical evidence, between the veteran's current symptoms and an inservice stressor; and credible supporting evidence that the claimed inservice stressor occurred. If the evidence establishes that the veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed inservice stressor. 38 C.F.R. § 3.304(f) (2001). See also Moreau v. Brown, 9 Vet. App. 389 (1996); Cohen v. Brown, 10 Vet. App. 128 (1997). The veteran's service personnel records indicate that he served with the Army in the Republic of Vietnam between February and October 1968. While in Vietnam, he was attached to the Army's 670th Transportation Company. A February 1983 VA hospital summary states that the veteran complained of PTSD symptoms. An impression of questionable PTSD was advanced. An April 1995 VA treatment record relates that the veteran complained of Vietnam-related flashbacks and dreams and associated insomnia. The report of the March 1995 VA examination for compensation purposes notes that the veteran related being involved in repeated ambushes while stationed in the Republic of Vietnam. At a March 1998 hearing before a VA hearing officer, the veteran testified that he experienced numerous stressful events while stationed in the Republic of Vietnam. He recalled that: he drove a vehicle in convoys which came under enemy sniper fire; a truck which he was driving ran over the head of a Vietnamese child; he witnessed the death of his friend George Campbell, a member of his unit, when the man's fuel tanker exploded near De Lok, Vietnam; and he witnessed the accidental death of Kelsey Layton who was killed when his weapon misfired. In reviewing the record, the Board observes that the veteran has not been requested to submit a written statement delineating the specific psychosocial stressors supporting his claim of entitlement to service connection for PTSD. The veteran's testimony and statements as to his stressful events have not been submitted to the United States Armed Services Center for Research of Unit Records (USASCRUR) for verification. The veteran's service medical records reflect that he was seen for gastrointestinal complaints on several occasions. A January 1968 treatment record states that the veteran complained of ulcer-like symptoms. A February 1968 upper gastrointestinal series revealed duodenal bulb deformity with no evidence of an active ulcer crater. An undated treatment entry relates that the veteran "has ulcers." An August 1974 VA upper gastrointestinal series revealed a slightly spastic and deformed duodenal bulb and no evidence of an active ulcer crater or niche. A July 1994 VA hospital summary reflects that the veteran presented a subjective history of peptic ulcer disease. VA treatment records dated in November 1995 and December 1995 state that the veteran was diagnosed with peptic ulcer disease. A March 1997 VA treatment record conveys that the veteran was being treated for peptic ulcer disease with Pepcid. A March 1997 VA upper gastrointestinal endoscopic evaluation showed focal erythema in the duodenal bulb and no erosions or ulcers. An April 1997 VA hospital summary states that the veteran was diagnosed with and treated for a Helicobacter pylori infection. A contemporaneous upper gastrointestinal series was reported to show a duodenal bulb scar. The report of a March 2000 VA examination for compensation purposes notes that the veteran's claims files were not available for review. The examiner did not identify either the veteran's service-connected regional ileitis or any chronic gastrointestinal disorder including peptic ulcer disease. As noted above, the Court has held that examinations for compensation and pension purposes conducted without contemporaneous review of the veteran's claims file are deficient for rating purposes. Proscelle v. Derwinski, 2 Vet. App. 629, 632 (1992). Therefore, the Board finds that further VA evaluation would be helpful in resolving whether the veteran has a chronic ulcer disease or any chronic residuals of his apparent inservice ulcer. A July 1967 Army treatment record reflects that the veteran was diagnosed with a hernia. A September 1981 VA hospital summary states that the veteran was diagnosed with acute prostatitis. A July 1994 VA hospital summary reflects that the veteran presented a history of prostatitis. A December 1995 VA treatment record states that the veteran reported a history of prostate cancer. A March 1997 VA gastroenterological evaluation notes that the veteran had a history of "PSA." At the March 1998 hearing on appeal, the veteran testified that he had developed a prostate disorder approximately eighteen months' prior to the hearing. He was unsure as to whether he had prostate cancer. The report of a March 1998 VA examination for compensation purposes states that a genital/rectal evaluation was deferred. Such an examination would be helpful in resolving the issues of the veteran's entitlement to service connection for both a chronic prostate disorder and a hernia. The veteran's claims for service connection have apparently not been considered under the VCAA. Therefore, the claims must be returned to the RO. Bernard v. Brown, 4 Vet. App. 384 (1993). In reviewing the reports of the VA examinations for compensation purposes conducted in March 1995, November 1996, and May 2000, the Board observes that the examiners were not provided with the veteran's claims files for review. The physicians noted that the veteran's current or recent alcohol use hampered their ability to accurately ascertain his current psychiatric disability picture. Varying diagnoses have been reported to account for the psychiatric symptoms present and the RO has determined that a higher rating is not in order as the anxiety reaction is not responsible for the current psychiatric symptoms. Applicable regulations provide that if the diagnosis of a mental disorder is changed, the rating agency shall determine whether the new diagnosis represents progression of the prior diagnosis, correction of an error in the prior diagnosis, or development of a new and separate condition. If it is not clear from the available records what the change of diagnosis represents, the rating agency shall return the report to the examiner for a determination. 38 C.F.R. § 4.125(b). Compliance with this regulation in the instant case requires an additional examination. The Court has held that the VA's statutory duty to assist the veteran includes the duty to conduct a thorough and contemporaneous examination so that the evaluation of the claimed disability will be a fully informed one. Green v. Derwinski, 1 Vet. App. 121, 124 (1991). Accordingly, this case is REMANDED for the following action: 1. The RO should request that the veteran provide information as to all treatment of his claimed PTSD, chronic ulcer disorder, chronic prostate disorder, left wrist disorder, chest disorder, eye disorder, blackouts, stiff-syndrome, gout, hernia, hypertension, chronic sleep disorder and service-connected anxiety reaction including the names and addresses of all treating health care providers. Upon receipt of the requested information and the appropriate releases, the RO should contact all identified health care providers and request that they forward copies of all available clinical documentation pertaining to treatment of the veteran for incorporation into the record. 2. The veteran should be requested to submit a written statement which conveys the specific psychosocial stressors which he alleges precipitated his PTSD. All information provided by the veteran should be as complete as possible and include all relevant dates, places, and unit assignments. 3. The RO should then submit the veteran's testimony and statements as to his alleged inservice stressors to the USASCRUR for verification. 4. The RO should request that copies of all VA clinical documentation pertaining to treatment of the veteran after November 1999 be forwarded for incorporation into the record. 5. The RO should then schedule the veteran for a psychiatric examination in order to determine the nature and severity of any psychiatric disability found together with the appropriate diagnosis(es) thereof. All indicated tests and studies, including psychological testing, should be accomplished and the findings then reported in detail. If a diagnosis of PTSD is advanced, the examiner should identify the specific stressors supporting such a diagnosis The claims folder must be made available to the examining physician. If a psychiatric disorder other than PTSD or anxiety neurosis is found to be present, the examiner must review the entire record and make a determination as to whether the new diagnosis represents progression of the prior diagnosis of anxiety disorder, correction of an error in the prior diagnosis, or development of a new and separate condition. The rationale for all opinions should be fully set forth. 6. Arrangements should also be made to have appropriate VA examinations conducted in order to determine the current nature of any chronic gastrointestinal, dermatological, ophthalmologic, genitourinary, vascular, orthopedic, and neurologic disorders present together with the proper diagnosis thereof. The appropriate examiner or examiners should express an opinion for the record as to: (1) whether it is at least as likely as not that the relevant identified physical disabilities were initially manifested during active service or are etiologically related to either Agent Orange exposure or the veteran's service-connected disorders; and (2) whether any of the identified disabilities increased in severity due to the service-connected disorders. The reasoning for the opinions expressed should be explicitly set forth. The claims files, including a copy of this REMAND, should be made available to the examiner or examiners. The examination report should reflect that such a review was conducted. 7. The RO must then review the claims files and ensure that all notification and development action required by the VCAA is completed. In particular, the RO should ensure that the new notification requirements and development procedures contained in 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West Supp. 2001) and 66 Fed. Reg. 45, 620 (Aug. 29, 2001) (to be codified as amended at 38 C.F.R §§ 3.102, 3.159, 3.326(a)) are fully met. 8. The RO should then readjudicate the veteran's claims of entitlement to service connection for PTSD, a chronic ulcer disorder, a chronic prostate disorder, a left wrist disorder to include a cyst, a chest disorder to include a cyst, a eye disorder, blackouts, stiff-man syndrome, gout, a hernia, hypertension, and a chronic sleep disorder and an evaluation in excess of 10 percent for his anxiety reaction to include the issue of whether the May 1996 reduction of the evaluation for that disability from 50 to 10 percent was proper with express consideration of the applicability of 38 U.S.C.A. § 1154 (West 1991); 38 C.F.R. §§ 3.304(f), 3.310(a), 3.344, 3.655, 4.1, 4.2, 4.13, 4.125 (2001); and the Court's holdings in Allen v. Brown, 7 Vet. App. 439 (1995) (concerning secondary service connection via aggravation) and Cohen v. Brown, 10 Vet. App. 128 (1997). If the claims remain denied, the veteran and his accredited representative should be provided with a supplemental statement of the case and be given the opportunity to respond. The veteran is free to submit additional evidence and argument while the case is in remand status. See Kutscherousky v. West, 12 Vet. App. 369 (1999). The veteran's claims must be afforded expeditious treatment by the RO. The law requires that all claims that are remanded by the Board or the Court for additional development or other appropriate action must be handled in an expeditious manner. See the Veterans' Benefits Improvement Act of 1994, Pub. L. No. 103-446, § 302, 108 Stat. 4645, 4658 (1994) and 38 U.S.C.A. § 5101 (West 1991) (Historical and Statutory Notes). In addition, the Veterans Benefits Administration's ADJUDICATION PROCEDURE MANUAL, M21-1, Part IV, directs the RO is 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. Thereafter, subject to current appellate procedures, the case should be returned to the Board for further appellate consideration if appropriate. The purpose of this REMAND is to allow for additional development of the record and due process of law. No inference should be drawn regarding the final disposition of the veteran's claims. C.W. Symanski Member, Board of Veterans' Appeals