BVA9401863 DOCKET NO. 93-21 987 ) DATE ) ) ) THE ISSUES 1. Entitlement to an increased evaluation for residuals of surgical repair of the left shoulder, currently evaluated as 10 percent disabling. 2. Entitlement to service connection for post-traumatic stress disorder. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD C. Chaplin, Associate Counsel INTRODUCTION This matter came before the Board of Veterans' Appeals (Board) on appeal from a rating decision of July 21, 1992, from the Chicago, Illinois, regional office (RO). The notice of disagreement was received on August 14, 1992. The statement of the case was issued on October 15, 1992. A supplemental statement of the case was issued on January 20, 1993. The substantive appeal was received on April 28, 1993. The appellant has been represented throughout his appeal by Disabled American Veterans, to which the file was referred. That organization submitted additional written argument to the Board on May 24, 1993. A hearing was held in September 1993 at the RO before W. H. Yeager, Jr., M.D., who is a member of the Board section rendering the determination in this claim and was designated by the Chairman to conduct that hearing, pursuant to 38 U.S.C.A. § 7102(b) (West 1991). The appeal was again received at the Board on September 29, 1993, and docketed on October 4, 1993. A transcript of the hearing was received in October 1993 and the case was subsequently referred for appellate consideration. The veteran had active service from March 1969 until June 1970. REMAND The veteran's claim is well-grounded, and, therefore, the Department of Veterans Affairs (VA) has a statutory obligation to assist him in the development of his claim. 38 U.S.C.A. § 5107(a) (West 1991). The veteran filed a claim in April 1992 seeking increased compensation for residuals of surgical repair of the left shoulder, evaluated as 10 percent disabling from June 17, 1970. Subsequently, in July 1992, he filed a claim for service connection for post- traumatic stress disorder. By a rating action in July 1992, the RO confirmed and continued the 10 percent evaluation for residuals of surgical repair of the left shoulder and denied service connection for post-traumatic stress disorder. The veteran was notified of this rating action, whereupon he initiated this appeal. At the personal hearing the veteran submitted a statement from the Department of Veterans Affairs (VA) Edward Hines Hospital that the veteran was scheduled for surgery on the left shoulder in October 1993. The record of this surgery would be helpful in rendering an equitable decision in this case. Additionally, the veteran should be examined for post-operative functional capacity. The United States Court of Veterans Appeals (Court) in Zarycki v. Brown, No. 92-976 (U.S. Vet. App. Dec. 20, 1993), set out guidelines to be followed in claims for service connection for post-traumatic stress disorder (PTSD). The Court points out that VA Manual M21-1 contains specific procedures for the VA to follow in evaluating claims for service connection based on PTSD. The evidence necessary to establish the occurrence of a recognizable stressor during service to support a claim of entitlement to service connection for PTSD depends on whether or the veteran was engaged in combat with the enemy. Therefore, specific findings of fact must be made as to whether or not the veteran was engaged in combat with the enemy and, if so, whether the claimed stressor is related to such combat. Where, the VA determines that the veteran did not engage in combat with the enemy, or that the veteran did engage in combat with the enemy but the claimed stressor is not related to such combat, the veteran's lay testimony, by itself, will not be enough to establish the occurrence of the alleged stressor. The record must contain service records which corroborate the veteran's testimony as to the occurrence of the claimed stressor. 38 U.S.C.A. § 1154(b) (West 1991); 38 C.F.R. § 3.304(d), (f) (1993); Manual M21-1, Part VA, para. 7.46(e)-(f); see Hayes v. Brown, 5 Vet.App. 60 (1993). Once the occurrence of a stressful episode is established, it then must be determined whether the claimed stressful event was of sufficient gravity to support a diagnosis of PTSD and whether the appellant's current PTSD is related to the claimed in-service stressful episode. Zarycki at 15. Accordingly, this claim is REMANDED for the following actions: 1. The RO should request all medical records from the Hines VA Medical Center from October 1993 to the present. These records should be made a part of the claims folder. 2. The veteran should be afforded a VA medical examination of the left shoulder to include post-operative functional capacity. 3. The RO should obtain a copy of the veteran's 201 file and associate the records with the claims folder. 4. The agency of original jurisdiction should request that the veteran provide a detailed statement regarding the traumatic events that he claims to have experienced in Vietnam, including names of others involved, units, dates, etc. 5. If adequate information is received, the originating agency should request assistance from the United States Army and Joint Service Environmental Support Group (ESG), 7798 Cissna Road, Springfield, Virginia 22150, in verifying information provided by the veteran. 6. The veteran should be contacted and requested to furnish a list of all medical personnel and facilities from which he has received treatment for any psychiatric disorder including post-traumatic stress disorder and substance abuse. The Board is particularly interested in the complete hospital records of any hospitalizations for any psychiatric illness. After obtaining appropriate releases from the veteran where necessary, the health care providers should be contacted and requested to provide all treatment records in their possession pertaining to the veteran. If these records are unavailable, that fact should be noted in the claims folder. Any available records should be associated with the claims folder. 7. The veteran should be afforded a special VA examination by a psychiatrist to determine the nature and extent of the veteran's post- traumatic stress disorder. All indicated studies should be performed, and the examination should be conducted in accordance with the Physician's Guide for Disability Evaluation Examinations. All necessary special studies or tests should be accomplished to include Minnesota Multiphasic Personality Inventory; the PTSD Rating Scale; Psychophysiological Assessment; and the Mississippi Scale for Combat-Related Post-Traumatic Stress Disorders. The diagnosis should be in accordance with DSM-III-R and the guidelines outlined therein to justify a clinical diagnosis of PTSD. The report of examination should contain a detailed account of all manifestations of the disability(ies) found to be present. If there are different psychiatric disorder(s) than the post-traumatic stress disorder, the examiner should reconcile the diagnoses and should specify which symptoms are associated with each of the disorder(s). If certain symptomatology cannot be disassociated from one disorder or another, it should be so specified. The examiner conducting the examination should describe the relationship between the post-traumatic stress disorder and any substance abuse and any personality disorder that the veteran may have. The examiner must specifically express an opinion as to whether the veteran's post- traumatic stress disorder caused substance abuse. The examiner must also express an opinion as to the impact of the post- traumatic stress disorder and related disability(ies) on the veteran's ability to obtain or retain substantially gainful employment. The examiner must provide full rationale for the opinions expressed. The entire claims folder and a copy of this remand must be provided to and reviewed by the examiner prior to the examination. The report of examinations should be comprehensive. 8. When this development has been completed, the claim should be reviewed by the originating agency. Initially, the RO should determine whether appellant was engaged in combat with the enemy, to examine the circumstances, conditions, and hardships surrounding his period of service, and, if necessary, to corroborate the occurrence of his alleged service-related stressors. Next, the RO should determine whether the claimed stressful event is a sufficient stressor to support a PTSD diagnosis. Finally, the RO should determine whether the appellant's current PTSD is related to the claimed in-service stressful episode. If the benefit sought on appeal is not granted, the appellant should be given a supplemental statement of the case with regard to the additional development and should also be afforded an opportunity to respond. The case should then be returned to the Board for further consideration. BOARD OF VETERANS' APPEALS WASHINGTON, D.C. 20420 W. H. YEAGER, JR., M.D. C. P. RUSSELL * *38 U.S.C.A. § 7102(a)(2)(A) (West 1991) permits a Board of Veterans' Appeals Section, upon direction of the Chairman of the Board, to proceed with the transaction of business without awaiting assignment of an additional member to the Section when the Section is composed of fewer than three Members due to absence of a Member, vacancy on the Board or inability of the Member assigned to the Section to serve on the panel. The Chairman has directed that the Section proceed with the transaction of business, including the issuance of decisions, without awaiting the assignment of a third Member. 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).