Citation Nr: 1124056 Decision Date: 06/24/11 Archive Date: 06/29/11 DOCKET NO. 05-39 008 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for heart disease (claimed as for heart implant and heart murmur). 2. Entitlement to service connection for memory loss and sleep problems, to include as due to an undiagnosed illness. 3. Entitlement to service connection for bilateral hip deterioration, to include as due to an undiagnosed illness.. 4. Entitlement to service connection for arteriosclerotic heart disease/hypertensive heart disease (claimed as clogged arteries of the heart), to include as due to an undiagnosed illness. 5. Entitlement to service connection for headaches, to include as due to an undiagnosed illness. 6. Entitlement to a compensable evaluation for hemorrhoids. 7. Entitlement to an evaluation higher than 10 percent disabling for gastritis, mild with ulceration and bleeding. REPRESENTATION Appellant represented by: Vietnam Veterans of America ATTORNEY FOR THE BOARD James G. Reinhart, Counsel INTRODUCTION The Veteran served on active duty from April 1979 to July 1992. This matter comes to the Board of Veterans' Appeals (Board) on appeal from September 2004 and August 2009 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. In the September 2004 decision the RO granted service connection for hemorrhoids and erosive gastritis with ulceration and bleeding and assigned initial ratings. The RO also denied service connection for heart implant. In the August 2009 decision, the RO denied service connection for memory loss and sleep problems, deterioration of the bilateral hips, headaches, and hypertensive vascular disease due to environmental hazards in the Gulf War. Of note, the Veteran filed claims for service connection for hypertension, depression, and alcoholism, all on a basis of other than as part of an undiagnosed illness. The RO denied those claims in January 2006 (hypertension) and December 2008 (depression and alcoholism), the Veteran did not appeal those decisions and those issues are not before the Board. FINDINGS OF FACT 1. Heart disease did not have onset during the Veteran's active service, did not manifest within one year of separation from active service, and are not etiologically related to his active service. 2. Bilateral hip deterioration did not have onset during the Veteran's active service, arthritis of his hips did not manifest within one year of separation from active service, and bilateral hip deterioration is not etiologically related to his active service. 3. Chronic headaches did not have onset during the Veteran's active service, chronic headaches did not manifest within one year of separation from active service, and chronic headaches are not etiologically related to his active service. 4. Memory loss and sleep problems did not have onset during the Veteran's active service and are not etiologically related to his active service. 5. During the course of his claim and appeal, the Veteran has not had an undiagnosed disease or multisymptom illness manifested by bilateral hip deterioration, sleep problems, memory loss, or clogged arteries of the heart. 6. Since the Veteran filed his claim for service connection, his gastritis, mild with ulceration and bleeding, has never resulted in more than chronic gastritis with small nodular lesions or more than gastric ulcer with recurring symptoms once or twice per year, and has never resulted in recurring severe symptoms two or more times per year averaging 10 days in duration, or in continuous moderate manifestations. 7. Since the Veteran filed his claim for service connection for hemorrhoids, he has not had large or thrombotic hemorrhoids, irreducible hemorrhoids, hemorrhoids with excessive redundant tissue, fissures, persistent bleeding with secondary anemia, or any impairment of sphincter control. CONCLUSIONS OF LAW 1. The criteria for service connection for heart disease (claimed as for heart implant and heart murmur) have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1131, 1137 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2010). 2. The criteria for service connection for chronic headaches have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1131, 1137 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2010). 3. The criteria for service connection for deterioration of the bilateral hips have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1131, 1137 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2010). 4. The criteria for service connection for memory loss and sleep problems have not been met. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. §§ 3.303, (2010). 5. The criteria for service connection for an undiagnosed illness manifested by memory loss, sleep problems, bilateral hip deterioration, headaches, and clogged arteries of the heart, due to service in Southwest Asia during the Gulf War have not been met. 38 U.S.C.A. §§ 1110, 1117, 5107 (West 2002); 38 C.F.R. § 3.303, 3.317 (2010). 6. The criteria for a compensable disability rating for hemorrhoids have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.114 Diagnostic Codes 7332, 7336 (2010). 7. The criteria for a disability rating higher than 10 percent for gastritis with ulceration and bleeding have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.114 Diagnostic Codes 7304, 7307 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303(a) (2010). "To establish a right to compensation for a present disability, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service"-the so-called "nexus" requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Certain chronic diseases, including cardiovascular disease, organic diseases of the nervous system, and arthritis, may be presumed to have been incurred in or aggravated by service if manifest to a compensable degree within one year of discharge from service, even though there is no evidence of such disease during service. 38 U.S.C.A. §§ 1101, 1112, (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.307, 3.309 (2010). The Veteran's DD 214 provides evidence that he served in Southwest Asia during the Persian Gulf War. Compensation may be paid to any Persian Gulf War veteran "suffering from a chronic disability resulting from an undiagnosed illness (or combination of undiagnosed illnesses)." 38 U.S.C.A. § 1117. These may include, but are not limited to, muscle pain, joint pain, neurologic signs or symptoms, and symptoms involving the respiratory system. 38 C.F.R. § 3.317(b). Such chronic disability must have manifested either during active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more no later than December 31, 2011, and must not be attributed to any known clinical diagnosis by history, physical examination, or laboratory tests. Objective indications of a chronic disability include both "signs," in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. Id. A qualifying chronic disability means a chronic disability resulting from any of the following (or any combination of the following): (A) an undiagnosed illness; (B) the following medically unexplained chronic multisymptom illnesses that are defined by a cluster of signs or symptoms: (1) chronic fatigue syndrome (CFS); (2) fibromyalgia; (3) irritable bowel syndrome (IBS); or (4) any other illness that the Secretary determines meets the criteria in paragraph (a)(2)(ii) of this section for a medically unexplained chronic multisymptom illness; or (C) any diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C.A. § 1117(d) warrants a presumption of service-connection. 38 C.F.R. § 3.317(a)(2)(i). To date, VA has identified any other medically unexplained chronic multi-symptom illnesses for purposes of 38 C.F.R. § 3.317. Accordingly, under these regulations service connection may be granted on a presumptive basis if there is evidence (1) that the claimant is a Persian Gulf veteran; (2) who exhibits objective indications of chronic disability resulting from an undiagnosed illness, a medically unexplained chronic multi- symptom illness (such as CFS, fibromyalgia, or IBS) that is defined by a cluster of signs or symptoms, or resulting from an illness or combination of illnesses manifested by one or more signs or symptoms such as those listed in paragraph (b) of 38 C.F.R. § 3.317; (3) which became manifest either during active military, naval, or air service in the Southwest Asia Theater of Operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2011; and (4) that such symptomatology by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C.A. §§ 1117, 1118; 38 C.F.R. § 3.317. Notwithstanding the foregoing presumptive provisions, the Veteran is not precluded from establishing service connection for a disease averred to be related to Gulf War service, as long as there is proof of such direct causation. See generally Combee v. Brown, 34 F.3d 1039, 1043-1044 (Fed. Cir. 1994). When addressing a claim on the merits, the Board has an obligation to evaluate the credibility of evidence and to assign probative weight to competent evidence. See Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (recognizing the Board's "authority to discount the weight and probity of evidence in light of its own inherent characteristics and its relationship to other items of evidence"). As to some of the factors that go into making these determinations both the Court of Appeals for Veterans Claims (Veterans Court) and the Court of Appeals for the Federal Circuit (Federal Circuit) have provided guidance. See Buchanan v. Nicholson, 451 F3.d 1331, 1336-37 (Fed. Cir. 2006) (stating that "the Board, as fact finder, is obligated to, and fully justified in, determining whether lay evidence is credible in and of itself, i.e., because of possible bias, conflicting statements, etc ".); see also Caluza v. Brown, 7 Vet. App. 498, 511 (1995) (stating that "[t]he credibility of a witness can be impeached by a showing of interest, bias, inconsistent statements, or, to a certain extent, bad character."). Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994) (explaining that competency has to do with whether the evidence may be considered by the trier of fact); see also Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). As to non-expert or lay opinions with regard to diagnoses or a relationship of a condition to service ("nexus"), whether such opinions are competent evidence depends on the question at issue and the particular facts of the case. Although it is error to categorically reject a non-expert nexus opinion, not all questions of nexus are subject to non-expert opinion. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). Whether a layperson is competent to provide a nexus opinion depends on the facts of the particular case. In Davidson, the Federal Circuit drew from its earlier decision in Jandreau v. Nicholson to explain its holding. Id. In that earlier decision, the Federal Circuit stating as follows: "[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The Federal Circuit provided an example, stating that a layperson would be competent to identify a simple condition such as a broken leg, but not competent to provide evidence as to a more complex medical question such as a form of cancer. Id. at n.4. Also of note is that the Veterans Court has explained that non-expert witnesses are competent to report that which they have observed with their own senses. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). Taking that decision together with the explanation in Layno, leads the Board to the conclusion that whether a non-expert nexus opinion or diagnosis is competent evidence depends on the complexity of the particular question and whether or not a nexus opinion could be rendered based on personal observation. In May 2004, VA first received a claim from the Veteran for compensation for disability due to heart implants, bleeding ulcers, and hemorrhoids. He specified that his heart disability began in October 1980 and that he was treated from October 1980 to May 2004 by Dr. "S.M." The RO granted service connection for the ulcer disability and hemorrhoids and denied service connection for heart implant in the September 2004 rating decision. In September 2005 he indicated that his claim should encompass disability due to heart murmur and claimed entitlement to service connection for hypertension. In his November 2005 substantive appeal, he contended that service connection should be granted for his heart condition, alleging that during service he sought treatment for his heart during service, the tests were inconclusive and he was treated for a murmur. The RO denied service connection for hypertension in January 2006. The Veteran did not initiate an appeal of that decision. In November 2008, he filed a claim stating his belief that medications provided him by the military, exposure to oil well fires, insects, and insecticides, caused a rapid deterioration of his health after separation from service. In January 2009 the RO sent him a letter asking him to provide specifics as to what he was contending such exposure and medication caused. He replied later that month as follows: "I feel I received clog arteries in the heart from months of exposure to smoke and elements from the burning oil wells during my tour in the middle east. I feel it's a combination of being expose to the pills & shots, insects and insecticides, have cause bone deterioration in my hip. I have headakhe [sic] memory lost and problem sleeping." The Board is aware that the RO characterized his claim for service connection for an undiagnosed illness as to include hypertensive vascular disease. However, this is not what the Veteran claimed. Rather, he specifically stated that he sought service connection for clogged arteries of the heart. He has been diagnosed with both essential hypertension and arteriosclerotic heart disease and has undergone angioplasty and stent placement in treatment of his disease of the left anterior descending artery. He has previously distinguished his vascular hypertension from his heart disease. Therefore, the Board has the relevant issue on the title page to accurately reflect the Veteran's claim. If he wishes to file a claim with the RO to reopen the claim for hypertension he may do so. Service treatment records are absent for any evidence that the Veteran suffered symptoms of heart disease, symptoms involving his hips, chronic headaches, or memory loss or sleep problems. Despite his report of seeking treatment for cardiac symptoms during service there is no evidence that he sought treatment or was treated for cardiac symptoms. There is no mention of heart murmur in the service treatment records. The service treatment records are therefore evidence against his claim as to service connection on a direct basis because the records tend to show that the Veteran did not have any symptoms of or treatment for heart disease of any kind, hip problems, chronic headaches, or memory loss or sleep problems. August 1987 notes include that the Veteran reported that his sinuses get clogged up and he gets migraines every once in a while. Assessment was to rule out common cold. In March 1988 he complained of a sore body, swollen lymph glands, swollen gums, a headache, and clogged sinuses of one days duration. He was assessed with an upper respiratory infection. In May 1988 he complained of chills, dizziness, and headaches. He was sent to the emergency room where he was found to have a smoker's type of red throat and diagnosed with some type of illness (illegible record in this regard). A day later he was diagnosed as having a local reaction to a tetanus toxoid. Although headaches are mentioned, there is no mention of chronic headaches and the headaches that he did report were not found to be chronic. The only mention of his heart is found in October 1990 treatment notes. He complained of cold symptoms, including a cough and heavy sputum. Physical examination revealed his heart to have "Strong, relaxed rate Normal rhythm." He was assessed with a viral syndrome. These notes are not evidence that he had any heart disease during service. In April 1992 he reported wheezing in his chest and a sharp pain on the right side of the abdomen as well as sore ribs and congested chest. The clinician heard the wheezing with palpation of the chest with stethoscope. He was diagnosed with bronchitis and prescribed Dimetapp, an inhaler, erythromycin, and robitussin. There is no mention in these records of memory loss or sleep problems There is no further mention of headaches after May 1988, tending to show that he did not have symptoms of an undiagnosed illness manifested by headaches or any headache disability but only an acute an transitory episode. The reports of congested chest and sore ribs were due to bronchitis, not heart problems. Despite the Veteran's contention that he was treated for heart murmur during service, the service treatment records, which appear complete, refer to other conditions, such as bronchitis, but do not mention a heart murmur. Although the Veteran reports that he had difficulty sleeping since service, there is no mention of sleep difficulties in his complete service records. Given that he reported other symptoms, it follows that if he had sleep problems (or for that matter memory problems) during service he would have reported those also. In short, the service treatment records are evidence against a grant of service connection for heart disease, sleep and memory problems, and a bilateral hip disability. The earliest post service treatment records are from 1998. In March 1998 "M.W.," M.D. referred the Veteran for an x-ray of his lumbar spine and right hip pursuant to a history of right hip pain. Results were a normal lumbar spine and a negative right hip. Dr. M.W. referred him to a neurologist and an August 1998 report shows that the Veteran had reported a history of right groin pain of five months duration and tingling in his right lower extremity of two weeks duration. The report, signed by "A.L.," M.D. includes a past medical history and review of symptoms showing no cardiorespiratory complaints and that the Veteran complained of pain in the right groin and numbness in the right leg. Neurological examination revealed spasms in the right lumbar region. Dr. A.L. provided an assessment that the Veteran may have lumbar radiculopathy but electromyography (EMG) and nerve conduction studies were normal with no evidence of radiculopathy, myopathy, or neuropathy. An MRI study of the Veteran's lumbar spine was normal. September 1998 followup includes Dr. A.L.'s report that the Veteran no longer had symptoms of his right groin and leg. An abdominal x-ray series from February 1999 includes findings that there were changes in the femoral heads consistent with avascular necrosis. This is evidence that the Veteran does have a disorder of his hips but that the disorder is a diagnosed disease. This, therefore, is evidence against his claim for service connection based on a 38 C.F.R. § 3.317 presumption of service connection for an "undiagnosed" illness. March 2001 treatment records from "T.M.," M.D. document that the Veteran had a regular heart rhythm and no murmurs. This is evidence that some nine years after service the Veteran did not have heart symptoms or a heart murmur. This is more evidence that the Veteran had no heart murmur during service as he did not have a heart murmur nine years after service, providing highly probative evidence against this claim. The earliest report of chest pain or suspicions of heart disease is found in March 2004 treatment notes from "S.M.," M.D. In a March 2004 letter Dr. S.M. explained that the Veteran was referred to him earlier that month following a recent abnormal stress test. He was found to have a soft systolic murmur over the precordium. Following diagnostic tests he was found to have a minimal sagging mitral valve and inferolateral ischemia. As a history, Dr. S.M. recorded that the Veteran had recently been experiencing some discomfort in his chest with occasional numbness and that a stress test done at Mesquite Community Hospital was normal. As a past medical history, Dr. S.M. noted that he had no history of essential hypertension. In March 2004 he underwent angioplasty and stent placement. Notes from May 2004 include a final diagnosis of arteriosclerotic heart disease status post PTCA (transluminal angioplasty) of LAD (left anterior descending artery), essential hypertension, hyperlipidemia, and chest pain with no evidence of myocardial infarction. These 2004 notes from Dr. S.M. are evidence against a finding that the Veteran had heart disease or murmur prior to 2004 because there is no mention in this report or in any of the treatment records that the Veteran reported ever having previous cardiac symptoms or reported that he had ever been told that he had a murmur. In the context of seeking treatment for potential heart problems, the Board finds that it is not believable that the Veteran would not report a history of heart disease or heart murmur if such a history existed. The Board therefore finds that the Veteran is not credible in his report that he had heart symptoms and/or a heart murmur during service. The September notes of treatment by Dr. T.M. document that the Veteran complained of ear pain that had been going on for the past week as well as headaches and nosebleeds. He was diagnosed with bilateral otitis media. Although notes from this practitioner through 2003 document numerous other reported symptoms, there is no other mention of headaches. This tends to show that even in 2003 he did not have chronic headaches but only acute and transitory symptoms. VA treatment notes document the Veteran's report of insomnia in April 2007. He reported that he tends to worry a lot, his brother was murdered in 2006, and the person had not been to trial. The assessment was depression not otherwise specified and bereavement. March 2007 treatment notes include the Veteran's report that he has not been able to sleep since he was in the military. Also of record are notes of alcoholism treatment provided for at Summer Sky Incorporated in 2005. He was diagnosed with alcohol dependency and post traumatic stress disorder and he did report some sleep problems. An April 2008 report of bilateral hip x-ray study yielded an impression of irregular bone architecture of each femoral head. The radiologist indicated that this was compatible with previous diagnosis of early avascular necrosis. September 2008 VA treatment notes includes the Veteran's report of hip pain which he described as stiffness. A rheumatology consult report addressed his report of achiness of his shoulders and wrists. Musculoskeletal physical examination revealed mild loss of internal rotation of the hips. Radiology studies included the same report from April 2008. Rheumatology clinic notes from January 2009 include a diagnosis of osteonecrosis of the hips. Again, because the Veteran's symptoms involving his hips have been assigned a diagnosis, those symptoms are not evidence of an undiagnosed illness and therefore service connection cannot be presumed for his bilateral hip condition by application of 38 C.F.R. § 3.317. In June 2009, the Veteran underwent a VA examination with regard to his claim for service connection based on service in Southwest Asia during the Gulf War. His reported symptoms were that since return from the Gulf War he had a moderate degree of fatigue, vitality of 20 percent less than what had been his normal, rashes on his back and leg described as atopic dermatitis, treated with cortisone creams. Those rashes were not present at the time of the examination but the Veteran reported that he did have a rash of his inguinal area and scrotum. He also reported a history of headaches in the temporal areas of his head, which he reported he had two or three times per week and lasted 10 to 15 minutes. He reported that the headaches were always of about the same severity and frequency. He also reported a history of stomach difficulties including ulcers. The report includes that the Veteran was diagnosed with heart problem in 2003 following ill defined chest pains. He reported that he currently has chest pains once per month. Following physical examination, the examiner provided an impression of tension headaches, gastric ulcer, esophageal reflux, hypertensive vascular disease, hypertensive cardiovascular disease, esophageal reflux, and hypercholesterolemia. The examiner included a comment that "[t]he difficulty with the skin, the headaches, the problem with his stomach, and with his heart, are not related to Gulf War service." He underwent a VA C&P examination of his hips in June 2009. The examiner indicated that he had reviewed the Veteran's claims file. He diagnosed aseptic necrosis of the hips with onset in 2006 and provided an opinion that the condition was not secondary to his Gulf War service, providing more evidence against this claim. He also underwent a VA mental diseases examination in June 2009. During the examination the Veteran reported that he felt depressed and stressed out at work and focused on his present occupation. Under a heading for mental status examination, the examiner noted the Veteran's report of decline in concentration and short term memory. The examiner commented that this is more likely than not related to his history of heavy alcohol abuse and that he had fair long term memory with gaps due to alcohol blackout spells, providing more evidence against this claim. When asked about specific psychological symptoms, the Veteran reported initial and middle insomnia with varying frequency, as well as hypervigilance. He also reports some anger an irritability, but mainly in the context of his perceived harassment at work. The examiner diagnosed adjustment disorder with depressed mood and anxiety and alcohol abuse in full sustained remission. The examiner noted that the Veteran had claimed subjective memory loss and sleep disturbance secondary to exposure to burning oil fields in Kuwait "but I find if less likely than not that those claimed symptoms relate to his military service. I find it more likely than not that they relate to his history of adjustment disorder, as well as residual problems secondary to a history of heavy drinking." These C&P examination reports are evidence against the Veteran's claims for service connection on either a presumed basis or on a direct basis for memory loss, headaches, sleep problems, a heart disorder (including a murmur) and a bilateral hip disorder. The mental diseases examination report attributed the Veteran's symptoms of insomnia and memory loss to his diagnosed alcoholism and an adjustment disorder. These symptoms, therefore, are not evidence of an undiagnosed illness. Service connection has not been established for alcoholism or adjustment disorder and therefore his sleep problems and memory loss are part of a non-service connected condition rather than symptoms of a disease or injury with onset during or due to service. The medical professional who conducted the Gulf War examination and the joints examination specifically stated that his claimed conditions were not due to his Gulf War service. It is recognized by the Board that the medical professional who conducted the Gulf War examination and the joint examination did not provide an explanation, or rationale, for his conclusion that the Veteran's claimed conditions were not due to his service during the Gulf War. In the context of this case, the Board finds that the examination is adequate. In this regard, there is no evidence in the claims file that any of his conditions, including headaches, his diagnosed hip disorder, or his heart disease, had onset during service or was directly caused by his service. There is only the Veteran's assertion, which began as a statement that he believed his Gulf War service caused a deterioration of his health. It is classically impossible to prove a negative and the Veteran has not met his burden of providing some evidence to support his claim. The mere assertion by a layperson as to his belief that exposure to insects, insecticide, medication provided by the military, and smoke from oil fires caused clog arteries in his heart, bone deterioration, and headaches, is not the presentation of any evidence to support a claim. Based on the above, under the facts of this case the Board can find little else that the examiner could have provided in way of a rationale. While it is possible that the examiner could have provided a review of the literature regarding causation of heart disease, headaches, and bone deterioration from Gulf War service, the examiner is a medical professional and some value must be assigned to that status. For these reasons the Board finds the examination adequate in this case, providing some evidence against these claims, outweighing the Veteran's lay statements. As to the Veteran's opinion that he clogged arteries, deterioration of the hips, sleep problems, memory loss, or headaches due to service, his opinion is not competent evidence. Causation of disease by factors such as insects, insecticides, medication, and smoke from oil fires is not something a lay person observe with their five senses. Nor are these simple questions. Rather, it is public and common knowledge that research by medical professionals and scientists is regularly conducted to determine whether environmental conditions and pharmaceuticals cause disease and/or result in unintended or "side" effects. Therefore, the Veteran's opinion in this regard is assigned no probative value because it is not competent evidence. Finally, the evidence, as described above, is against a finding that the arteriosclerotic heart disease/hypertensive heart disease, organic neurological disease, or arthritis manifested within one year of separation from active service and therefore the provisions for chronic diseases, at 38 C.F.R. § 3.307 and § 3.309 are not for application. Based on the above analysis, the Board concludes that the preponderance of evidence in this case is against a finding that the Veteran has a hip disorder, heart disease, memory loss, insomnia, or headaches that had onset during service, were caused by his service, or that service connection can be presumed for any of these claimed conditions. Hence, his appeal as to his claims for service connection must be denied. There is no reasonable doubt to be resolved as to this issue. See 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2010); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Increased ratings Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran's disability. 38 C.F.R. §§ 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). If the disability more closely approximates the criteria for the higher of two ratings, the higher rating will be assigned; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. Also considered by the Board is whether referral is warranted for a rating outside of the schedule. To accord justice in an exceptional case where the scheduler standards are found to be inadequate, the field station is authorized to refer the case to the Chief Benefits Director or the Director, Compensation and Pension Service for assignment of an extraschedular evaluation commensurate with the average earning capacity impairment. 38 C.F.R. § 3.321(b)(1) (2010). The criterion for such an award is a finding that the case presents an exceptional or unusual disability picture with related factors as marked interference with employment or frequent periods of hospitalization as to render impractical application of regular schedular standards. 38 C.F.R. § 3.321(b). The Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance; however, the Board is not precluded from raising this question, and in fact is obligated to liberally read all documents and oral testimony of record and identify all potential theories of entitlement to a benefit under the law and regulations. Floyd v. Brown, 9 Vet. App. 88 (1996). Extraschedular consideration involves a three step analysis. Thun v. Peake, 22 Vet. App. 111 (2008). First, the Board or the RO must determine whether the schedular rating criteria reasonably describe the Veteran's disability level and symptomatology. Id. at 115. If the schedular rating criteria do reasonably describe the Veteran's disability level and symptomatology, the assigned schedular evaluation is adequate, referral for extraschedular consideration is not required, and the analysis stops. Id. If the RO or the Board finds that the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology, then either the RO or the Board must determine whether the Veteran's exceptional disability picture includes other related factors such as marked interference with employment and frequent periods of hospitalization. Id. at 116. If this is the case, then the RO or the Board must refer the matter to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for the third step of the analysis, determining whether justice requires assignment of an extraschedular rating. Id. This appeal stems from the rating decision, issued in September2004, in which the RO granted service connection for hemorrhoids and mild erosive gastric with ulceration and bleeding. In deciding this appeal, the Board has considered whether separate ratings for different periods of time, based on the facts found, are warranted, a practice of assigning ratings referred to as "staging the ratings." See Fenderson v. West, 12 Vet. App. 119 (1999). Gastritis The RO listed the Diagnostic Code for its assignment of a 10 percent rating for erosive gastritis as 7307-7304. In rating disability due to diseases, the preference is to be given to the disease itself; if the rating is determined on the basis of residual conditions, the number appropriate to the residual condition will be added, preceded by a hyphen. Thus, the RO has rated the disease gastritis (38 C.F.R. § 4.114 Diagnostic Code 7307) on the basis of the residual condition, gastric ulcer (38 C.F.R. § 4.114 Diagnostic Code 7307). The rating schedule provides that severe gastric ulcer with pain only partially relieved by standard ulcer therapy, periodic vomiting, recurrent hematemesis or melena, with manifestations of anemia and weight loss productive of definite impairment of health, a 60 percent rating is assigned. 38 C.F.R. § 4.114, Diagnostic Code 7304. Moderately severe gastric ulcer which is less than severe but with impairment of health manifested by anemia and weight loss; or recurrent incapacitating episodes averaging 10 days or more in duration at least four or more times a year is assigned a 40 percent rating. Id. Moderate; recurring episodes of severe symptoms two or three times a year averaging 10 days in duration; or with continuous moderate manifestations is assigned a 20 percent rating. Id. Mild gastric ulcer with recurring symptoms once or twice yearly is assigned a 10 percent rating. Id. Also considered by the Board are the rating criteria for the disease entity, gastritis. Chronic gastritis with severe hemorrhages, or large ulcerated or eroded areas is assigned a 60 percent rating. 38 C.F.R. § 4.114, Diagnostic Code 7307. Chronic gastritis with multiple small eroded or ulcerated areas, and symptoms is assigned a 30 percent rating. Id. Chronic gastritis with small nodular lesions, and symptoms is assigned a 10 percent rating. Id. Ratings under Diagnostic Codes 7301 to 7329, inclusive, will not be combined with each other but, rather, a single evaluation will be assigned under the diagnostic code which reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such an elevation. 38 C.F.R. § 4.114. Service treatment records do not provide evidence current enough to reflect the Veteran's disability at the time that he filed his claim for service connection. Of record are treatment notes from "F.S.," M.D. May 2004 treatment notes document that the Veteran was admitted with hematemesis and significant upper gastrointestinal bleeding. He underwent a esophagogastroduodenoscopy (EGD) including cauterization of an esophageal ulcer. A July 2004 EGD procedure report documents that the Veteran underwent another EGD due to history of esophageal ulcer. The impression was healed esophageal ulcer, small hiatal hernia, and no gastric or duodenal ulcers. A follow up in August 2004 includes an entry that he had a healed esophageal ulcer. A January 2005 entry includes a report that the Veteran had left upper quadrant pain, probably of the muscular wall. There is no evidence that this was due to an ulcer. In August 2004 he underwent a VA C&P examination with regard to his gastric condition. The examiner indicated that the RO had not provided the claims file or service records for review but the relevant history provided by the Veteran during the examination is not significantly different from what is found in the claims file. The Veteran reported that he underwent a surgical procedure in 1997 to cauterize gastric bleeding. The examiner noted that the Veteran was not currently anemic. During the examination the Veteran reported that he had lost 4 months of work due to gastrointestinal bleeding in the past year. During this examination examiner stated that in May and July of 2004 the Veteran had gastric bleeding episodes and he stated that the bleeding was more likely than not from an upper gastrointestinal source as opposed to an ano-rectal source. The examiner provided an impression of upper gastrointestinal ulceration with bleeding and speculated that this was likely related to enterogastritis with ulceration. He also stated that the Veteran had erosive gastritis as shown on an upper gastrointestinal series. An attached report includes an impression of mild erosive gastritis. Another VA C&P examination was afforded the Veteran in March 2006. The examiner stated that the claims file was available for this examination and indicated review of the file, noting relevant evidence. The examiner interpreted the evidence from May and July 2004 as two gastrointestinal bleeds with EGD performed both times including cauterization in May 2004 and for mainly diagnostic purpose in July 2004. The examiner also stated that the Veteran has been anemic in the past. Continuing to report the relevant history, the examiner stated that an upper GI x-ray from November 2004 was normal and in September 2005 an upper GI showed mild erosive gastritis. The examiner stated that currently the Veteran had occasional abdominal pains once per month and some nausea, but not very often. He also stated that the Veteran had occasional has loose stools but not very often. The Veteran denied melena or bright red blood in the stools, his weight was stable, and he had a good appetite. Diagnosis was erosive gastritis and mild ulceration, no residuals or bleeding. In addendum, he indicated that the claims file had been reviewed and remarked only that the Veteran had a small duodenal ulcer noted on an upper gastrointestinal series taken during service. Taking the aforementioned evidence together, the Board finds that the evidence is against assigning a rating higher than 10 percent under any applicable criteria. Although the Veteran had a significant gastrointestinal bleed in May 2004, the July 2004 EGD did not show a significant gastrointestinal bleed and there is no evidence from when he filed his claim through the date of the March 2006 C&P examination that he had any other severe symptoms. Thus, his disability did not approximate the criteria of moderate recurring episodes of severe symptoms two or three times a year averaging 10 days in duration. Rather he had one severe symptom in May 2004 and the evidence does not show that this lasted 10 days. Nor did his disability approximate the criteria for a rating higher than 10 percent under Diagnostic Code 7307. There is no evidence that he had multiple small eroded or ulcerated areas. Although he suffered one severe bleed in May 2004, the criteria for a 60 percent rating clearly refers to severe hemorrhages, in the plural. Considering both diagnostic codes and the Veteran's symptoms during this time, his overall disability was so severe to approximate elevating his rating to the next higher rating. In February 2008 an upper gastrointestinal study was conducted. The impression was normal upper gastrointestinal series, providing evidence against this claim. The Veteran underwent a CT of the abdomen in March 2008 following complaints of abdominal pain of the right upper quadrant. The impression did not include any statement regarding his digestive system. In September 2008, the Veteran again underwent a relevant C&P examination, including review of the claims file. The history provided in the 2006 report was again provided and he currently had no history of nausea, vomiting, or hematemesis There was no history of peritoneal adhesions since the EGD treatment. He had not had any bleeding episodes since the last C&P examination. He reported that he did have some gastrointestinal tract problems in the form of abdominal cramps, mostly on the side, and occurring 2 to 3 times per month. He described the pain as similar to gas and passing of flatus tended to help the discomfort. He reported that he misses two days of work per month due to these symptoms. The Veteran's weight was stable and he had no signs of anemia. Physical examination was essentially unremarkable. There were no clinical signs of anemia. Diagnosis was gastrointestinal tract ulcers, past history of bleeding, currently positive occult test on examination. In June 2009, the Veteran underwent a VA C&P "Gulf War Guidelines" examination. The history recorded in that report is not different from previous examinations and other than the report that the has reflux controlled by medication, all references to his gastrointestinal system difficulties are from prior to the last C&P examination. An impression included an entry that he had a now healed gastric ulcer. An upper gastrointestinal series, from July 2009, includes findings that no active ulcer was identified. The impression was chronic changes related to previous peptic ulcer disease involving the duodenal bulb. Also of record are VA treatment notes through May 2010. These notes include no reports of gastrointestinal symptoms. This is important for two reasons. First, the treatment notes which note other conditions but not gastrointestinal symptoms or complaints tends to show that a higher rating is not warranted for the period encompassed by the notes. Second, although the last examination was conducted in 2008, the absence of any new symptoms or evidence of increased disability in the complete treatment notes tends to show that another examination is not necessary in this case for the Board to decide the appeal. Thus, the medical evidence, as a whole, shows that the Veteran does not have more than mild gastric ulcer and has not had more than one or two recurrent symptoms per year since that time. Similarly, the evidence shows that the Veteran's service connected gastrointestinal disability has not resulted in any severe symptoms and therefore does not approximate the criteria for a higher rating under Diagnostic Code 7307. Nor is there a basis for referring this issue for extraschedular consideration. The rating criteria just discussed addresses all of the manifestations of the Veteran's gastritis with ulceration and bleeding because it addresses pain and bleeding. That criteria also addresses disability worse than the Veteran's as it addresses severe hemorrhages, recurrent hematemesis or melena, and weight loss productive of definite impairment of health. As the rating criteria contemplates both the degree and symptomatology of the Veteran's gastritis with ulceration and bleeding, the first prong of the Thun test is not satisfied. The Board therefore declines to remand the issue for referral for extraschedular consideration. Based on the above, the Board finds that the preponderance of the evidence is against assigning a rating higher than 10 percent for the Veteran's gastritis with ulceration and bleeding for any period on appeal. His appeal as to this issue must therefore be denied. There is no reasonable doubt to be resolved as to this issue. See 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2010); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Hemorrhoids The rating schedule provides for a noncompensable (0 percent) rating for mild or moderate internal or external hemorrhoids. 38 C.F.R. § 4.114, Diagnostic Code 7336. Hemorrhoids with persistent bleeding and with secondary anemia, or with fissures, are rated 20 percent disabling. Id. Large or thrombotic hemorrhoids, irreducible, with excessive redundant tissue, evidencing frequent recurrences, are rated 10 percent disabling. Id. Diagnostic Code 7332 provides ratings based on impairment of sphincter control, with regard to the rectum and anus. 38 C.F.R. § 4.114, Diagnostic Code 7332. Complete loss of sphincter control is rated 100 percent disabling. Id. Extensive leakage and fairly frequent involuntary bowel movements are rated 60 percent disabling. Id. Occasional involuntary bowel movements, necessitating wearing of pad, are rated 30 percent disabling. Id. Constant slight impairment of sphincter control, or occasional moderate leakage, is rated 10 percent disabling. Id. Healed or slight impairment of sphincter control, without leakage, is rated as noncompensable. Id. Service treatment records do not provide evidence current enough to determine the extent of disability due to hemorrhoids relevant to the time the Veteran filed his claim in May 2004. An operative report from May 2001, from "R.K," M.D. documents that the Veteran then underwent ligature assisted internal and external hemorrhoidectomy. April 19, 2002 treatment notes from Dr. "T.M." document that the Veteran had a painful bowel movement a week before and was experiencing blood in his stools since then. Objectively he had normal sphincter control. He was assessed with rectal bleeding. Dr. R.K. informed Dr. T.M., by letter in April 2002, that on examination the Veteran had no internal hemorrhoids and no external hemorrhoids. The August 2004 VA C&P examination included examination of relevant to his hemorrhoids. At that time the Veteran reported that he had undergone hemorrhoid surgery to address bleeding in 2001 and the surgery had solved that problem. He reported that he will occasionally see a small amount of blood on toilet tissue after he has a stool. The examiner noted that the RO had not provided the claims file or service records for review. The Board notes that the evidence in the claims file is not inconsistent with the Veteran's reports during the examination. The examiner did however conduct a physical examination of the Veteran. Digital rectal examination and guaiac on a very small amount of brown stool was negative. He provided an impression of occasional mild hemorrhoidal bleeding. This report is evidence against granting a compensable rating under Diagnostic Code 7336, for hemorrhoids. Although the examiner did not review the claims file, the history provided by the Veteran was accurate and the claims file adds nothing to the disability picture for the period after which the Veteran filed his claim for service connection. Moreover, the Veteran described his bleeding as occasional which tends to show that he did not have persistent bleeding. As the examiner did conduct a physical examination, the results tend to show that he had no fissures, or large or thrombotic hemorrhoids because it would be unusual that if these were present the examiner would not make some comment in that regard. Additionally, if he had fissures or large or thrombotic hemorrhoids at the time of the examination, it does not follow that the examiner would report that the 2001 surgery had a good result. The March 2006 VA C&P examination also included examination with regard to the Veteran's hemorrhoids and included review of the claims file. The Veteran reported that he occasionally had nausea and loose stools but not very often. He denied any blood in his stools. Specifically addressing his hemorrhoids, the Veteran reported that he has not had any hemorrhoid problems in a very long time. He reported that he noticed blood on the toilet tissue one month ago, the blood lasted one day, and he had no current rectal bleeding, pain, itch, or burning sensation. Rectal examination revealed no hemorrhoids present, digital examination revealed no palpable hemorrhoids, and there was negative hemoccult with control Diagnosis was external hemorrhoids, no residuals. This examination report is evidence against his claim because he reported no difficulty with hemorrhoids for a very long time and physical examination found no hemorrhoids or residuals of hemorrhoids. This is, therefore, evidence against a compensable rating for hemorrhoids under Diagnostic Code 7336 because it shows that the Veteran is asymptomatic in this regard. His reports of occasional loose stools is not a report of loss of sphincter control. There is no indication from this report that he had or had ever had any loss of sphincter control. His addressing of his bathroom history during the examination report, without report of leakage, is evidence against assigning a compensable rating under Diagnostic Code 7332. A December 2006 colonoscopy report includes that the Veteran had two medium grade internal hemorrhoids. Notes from Dr. F.S. from the following month indicate that this was conducted because the Veteran reported rectal bleeding. September 2007 VA treatment notes include that the Veteran denied blood in stool. February 2008 VA treatment notes include the Veteran's report of abdominal pain but no actual blood in the bowels. Other notes from this month include that he has occasional dark stools. This evidence does not support a compensable rating for the Veteran's hemorrhoids. Taken together, this evidence from December 2006 through February 2008 is against assigning a compensable rating for disability due to hemorrhoids. First, the Veteran has not reported suffering any leakage. Second, the hemorrhoids that were found on colonoscopy were described as medium, thereby precluding a finding that they were large. There is no evidence that he had any redundant tissue or thrombotic hemorrhoids, either from the colonoscopy report or the examination. Probative that there was no redundant tissue or thrombotic hemorrhoids is that hemorrhoids were not detectable on physical examination. The September 2008 VA C&P examination included examination with regard to his hemorrhoids. The Veteran reported some recent dark brown stools with no recurrent melena. It was noted that he had consistently soft stools but no diarrhea. He reported anal itching present for several years, that he had soft stools with intermittent pain in rectal area. He reported that he has noted fecal leakage on occasion with some underwear staining. He reported and the examiner noted that the Veteran has never had fissures, anal infections, or fistula-in-ano on examination. The examiner stated that there was rectal bleeding noted by the Veteran after bowel movements on a daily basis, with streaks on tissue and occasionally noted on his shorts. Physical examination showed good anal sphincter tone and no external hemorrhoids. Nor were any internal hemorrhoids palpated. Occult test was weakly positive on examination. Diagnosis was that the Veteran currently had no active hemorrhoids on examination, with reported rectal bleeding which the examiner attributed to the internal hemorrhoids shown by colonoscopy in 2007. As mentioned above, the evidence from Dr. F.S. documents that the Veteran has had bleeding due to his gastric ulcer disease. Also as noted in the section addressing his gastric ulcer disease, he has been anemic in the past. However, all of those references are to anemia and bleeding due to the ulcerative gastritis. There is no indication that he has ever been anemic or had other than occasional bleeding, as opposed to persistent bleeding, due to his hemorrhoids. He reported daily bleeding evidenced by blood on tissue and occasionally in his shorts after bowel movement. This, however, does not approximate the criteria for a rating under Diagnostic code 7336. That criteria does include "persistent bleeding with secondary anemia." However, the secondary anemia in this rating criteria must inform the "persistent bleeding" as it tends to address the level or amount of the bleeding and would have no other logical reason for being included in the rating criteria for hemorrhoids. Also importantly, he does not have large or thrombotic hemorrhoids that are irreducible and result in excessive redundant tissue. The level of disability resulting from streaks of blood on toilet paper after a bowel movement and occasional streaks in his shorts, does not rise to the level contemplated by the 20 percent rating as it does not appear to result in as much disability, i.e. effect on earning capacity, as the criteria for a 10 percent rating indicates. He has never been found to have fissures. The Board therefore concludes that this evidence tends to show that his hemorrhoids do not approximate the criteria for a compensable rating under Diagnostic Code 7336. His reports of leakage also do not approximate the criteria for a compensable rating under Diagnostic Code 7332. The Veteran has consistently been found to have good sphincter tone which tends to show that he has no sphincter impairment. That he has underwear staining on occasion, given the finding of good sphincter tone, is not evidence of sphincter impairment but is more properly viewed as a matter of simple hygiene. Although there are VA treatment records throughout May 2010, those records do not include any complaints of symptoms involving the Veteran's hemorrhoids. The evidence after February 2008 tends to show that a compensable rating is not warranted for disability due to the Veteran's hemorrhoids. Moreover, those records tend to show that there is no need for a more recent examination with regard to his hemorrhoids because it does not appear that there has been any change since the last examination. Finally, there is no basis for referring this issue for extraschedular consideration. The Veteran has reported itching and burning, which are manifestations not addressed by the rating criteria. However, the second prong of the Thun test is not met here. There have been no hospitalizations and there is no evidence that his hemorrhoids have resulted in marked interference with employment, or any similar related factors. The Board therefore declines to remand this issue to the RO for referral for extraschedular consideration. For the reasons stated above, the Board finds that the preponderance of evidence of record is against assigning a compensable disability rating for disability due to the Veteran's hemorrhoids for any period of time on appeal. His appeal as to this issue must therefore be denied. There is no reasonable doubt to be resolved as to this issue. See 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2010); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Duties to notify and assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2010). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). For service-connection claims, this notice must address the downstream elements of disability rating and effective date. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The issues of entitlement to compensable/higher ratings for the disabilities his ulcerative gastritis and hemorrhoids are before the Board because he disagreed with the ratings assigned in the rating decision in which service connection for these conditions was established. Because it is the claim that triggers the VCAA notice duty, the notice required with regard to these claims is the notice required for a claim of entitlement to service connection. Here, the VCAA duty to notify was satisfied by way of a letters sent to the Veteran in June 2004, October 2005, May 2008, February 2009, and June 2009. The June 2004 letter addressed the claims for service connection for heart disease, ulcers, and hemorrhoids, although it did not provide notice with regard to assignment of effective dates and disability ratings. The October 2005 letter provided additional notice with regard to the claim for service connection for a heart condition. The May 2008 letter provided adequate notice with regard to disability ratings for gastritis and hemorrhoids. The February 2009 letter provided adequate notice with regard to the claims for service connection for headaches, memory loss, sleep problems, and clogged arteries, due to service in the Gulf War and on a direct basis and included notice with regard to disability ratings and effective dates. The June 2009 letter provided adequate notice with regard to the claim for service connection for deterioration of the Veteran's hips. To the extent that notice was not provided with regard to assignment of effective dates for the gastritis, hemorrhoid, and heart claims it does not appear that the Veteran suffered any prejudice from this lack of notice. He has not contested the effective date assigned for any of his claims that have been granted. To the extent that the notice was not timely with regard to disability ratings for the claims involving gastritis and hemorrhoids, since the notice was provided the Veteran has had sufficient opportunity since the notice was provided to participate meaningfully in the processing of claim and the RO has readjudcicated the appeal by issuance of supplemental statements of the case in November 2009 and February 2010, curing the timing defect. See Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as a statement of the case or supplemental statement of the case, is sufficient to cure a timing defect). As there is no indication that the Veteran has been prejudiced by any of the aforementioned notice defects, the Board does not find it necessary to remand the case to the RO for additional notice. See generally Shinseki v. Sanders 129 S.Ct. 1696 (2009); see also 38 C.F.R. § 19.9 (2010). VA has a duty to assist the Veteran in the development of the claim. This duty includes assisting the Veteran in the procurement of service and other pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The RO has obtained service treatment records, VA treatment records, and all treatment records for which the Veteran has requested assistance in obtaining have been obtained and associated with the claims file. VA afforded the Veteran adequate examinations in August 2004 (gastritis and hemorrhoids), March 2006 (gastritis and hemorrhoids), September 2008 (gastritis and hemorrhoids), and June 2009 (hips, Gulf War claim, including insomnia and memory loss and heart disease and headaches). VA did not afford the Veteran an examination to determine if heart disease was directly related to service. However, the Board finds that VA has no duty to do so in this case. In determining whether the duty to assist requires that a VA medical examination be provided or medical opinion obtained with respect to a veteran's claim for benefits, there are four factors for consideration. These four factors are: (1) whether there is competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) whether there is evidence establishing that an event, injury, or disease occurred in service, or evidence establishing certain diseases manifesting during an applicable presumption period; (3) whether there is an indication that the disability or symptoms may be associated with service or with another service-connected disability; and (4) whether there otherwise is sufficient competent medical evidence of record to make a decision on the claim. See 38 U.S.C. § 5103A(d);38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). Here the evidence does not establish an event, injury, or disease which occurred during service or establish that heart disease manifested within one year of separation from active service. As this factor is not present, the Board declines to remand the case to provide an examination with regard to his claim for service connection for heart disease on a direct basis. The post-service treatment records only provide highly probative evidence, overall, against this claim. The Board has considered the Veteran's representative's argument that a new examination is needed to rate his gastritis and hemorrhoids. There is, however, no indication in the record that there has been a change in the disability suffered by the Veteran due to these conditions. The examiner has also argued that the examiner did not consider "DeLuca" factors in rating the Veteran's hemorrhoids and gastritis. This argument is without merit. In Deluca v. Brown, 8 Vet. App. 202, the Veterans Court addressed application of 38 C.F.R. § 4.40 and § 4.45 in cases involving the rating of musculoskeletal disabilities. The Veteran's hemorrhoid and gastritis disabilities do not involve the musculoskeletal system and DeLuca has not no direct application. Neither the Veteran nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist under the VCAA. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). ORDER The appeal is denied as to all issues. ______________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs