Citation Nr: 1343364 Decision Date: 12/31/13 Archive Date: 01/07/14 DOCKET NO. 10-14 918 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUE Entitlement to service connection for residuals of shrapnel wounds to the left leg and buttocks. REPRESENTATION Veteran represented by: Georgia Department of Veterans Services ATTORNEY FOR THE BOARD J.N. Moats, Counsel INTRODUCTION The Veteran served on active duty from June 1966 to May 1968. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2008 rating decision issued by the Cleveland, Ohio "Tiger Team" Regional Office (RO) of the Department of Veterans Affairs (VA). Jurisdiction was subsequently transferred to the Atlanta, Georgia, RO, which is located in Decatur, Georgia. The issues of entitlement to service connection for bilateral hearing loss and posttraumatic stress disorder (PTSD), and entitlement to nonservice-connected pension were also on appeal and, in addition to the issue listed on the title page, the RO addressed these matters in a January 2010 statement of the case. However, in his April 2010 substantive appeal, the Veteran limited his appeal as to the issues of entitlement to service connection for residuals of shrapnel wounds to the left leg and buttocks and PTSD. As such, the issues of entitlement to service connection for bilateral hearing loss and entitlement to nonservice-connected pension are not currently before the Board. Additionally, a subsequent rating decision in August 2013 granted service connection for PTSD. Thus, as this was a full grant of the benefit sought on appeal, this issue is no longer in appellate status. As a final preliminary matter, the Board notes this appeal was processed using the Virtual VA and the Veteran Benefits Management System (VBMS) paperless claims processing systems. Accordingly, any future consideration of this Veteran's case should take into consideration the existence of these electronic records. This appeal is REMANDED to the VA RO. VA will notify the Veteran if further action is required. REMAND A review of the record indicates that further development is necessary with respect to the issue on appeal. The Veteran contends that he incurred shrapnel wounds to his left leg and buttocks sides while stationed in Vietnam. He further contends that he was treated for these injuries in Vietnam by a field medic. The Board acknowledges that service personnel records included in the claims folder reflect the Veteran's service in the Republic of Vietnam. He is in receipt of the Vietnam Service Medal and the Vietnam Campaign Medal. His military occupational specialty for the applicable service period was heavy vehicle driver. However, service treatment and personnel records contain no complaints, findings, or diagnosis relating to shell fragment wounds. Indeed, the service examination prior to discharge in 1968 contains a normal clinical evaluation of all systems. Although service treatment and personnel records are silent with respect to any such injuries, the Veteran has consistently reported that he was in a combat situation where he suffered from shrapnel injuries. Moreover, post-service VA treatment records document complaints of left leg pain due to shrapnel wounds in Vietnam. An assessment indicated that the Veteran had muscle pains from left leg gunshot wounds. Further, a February 2009 mental health record indicated that the Veteran again reported suffering from shrapnel wounds and showed a scar on his left leg. Moreover, an August 2013 VA psychiatric examination report found that the Veteran met the criteria for PTSD due to a fear of hostile military activity based on the Veteran's reported shrapnel wounds. The Veteran has not been afforded a VA examination with respect to this issue. Based on the evidence currently on file, and in consideration of the Veteran's assertions that he received shrapnel wounds while stationed in Vietnam, the Board believes that the threshold requirements discussed in McLendon v. Nicholson, 20 Vet. App. 79 (2006), are arguably met with respect to this claim, warranting an examination in accordance with the duty to assist. Moreover, the record shows that the Veteran receives continuous treatment at the VA. With the exception of the August 2013 psychiatric evaluation, the most recent treatment records associated with Virtual VA and VBMS appear to be dated from April 2010. In light of the need to remand, additional ongoing VA treatment records should also be obtained. Accordingly, the case is REMANDED for the following action: 1. The AOJ should obtain the Veteran's VA treatment records, dated from April 2010 to the present. All reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C.A. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 2. After obtaining any outstanding treatment records, the Veteran should be scheduled for a VA examination. Any pertinent evidence contained within Virtual VA and VBMS as well as a copy of this remand must be made available to and reviewed by the examiner in conjunction with the examination. All necessary tests should be conducted and the examiner should review the results of any testing prior to completion of the report. The examiner shoulder offer opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran has any residuals to the left leg and buttocks from shell fragment wounds suffered during service in Vietnam. The report of examination must include a complete rationale for all opinions expressed and must specifically discuss the Veteran's lay assertions and any evidence of record inconsistent with the conclusions reached. 3. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the issue on appeal should be readjudicated based on the entirety of the evidence. If the claim remains denied, the Veteran and his representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board 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 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2013). _________________________________________________ A. JAEGER Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. 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) (2013).