Citation NR: 9721958 Decision Date: 06/24/97 Archive Date: 06/30/97 DOCKET NO. 95-00 577 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for hypertension. 2. Entitlement to service connection for a chronic left knee disability. 3. Entitlement to a compensable rating for service-connected hemorrhoids. 4. Entitlement to a compensable rating for service-connected vaginitis. 5. Entitlement to a compensable rating for a service- connected bunion of the left foot. 6. Entitlement to a compensable evaluation for a service- connected ingrown toenail, left great toe, with a history of fungal infection. 7. Entitlement to service connection for Eustachian tube dysfunction with hearing loss. 8. Entitlement to service connection for a chronic lung disability. 9. Entitlement to service connection for a chronic back disability. 10. Entitlement to service connection for a chronic left elbow disability. 11. Entitlement to a 10 percent rating under the provisions of 38 C.F.R. § 3.324 for separate noncompensable service- connected disabilities, from October 1, 1992, to April 15, 1994. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD Louis J. George, Associate Counsel INTRODUCTION The veteran served on active duty from May 1978 to September 1992. She had unverified active service from May 1976 to May 1978. This claim comes before the Board of Veterans’ Appeals (Board) on appeal from a February 1994 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama, which denied entitlement to service connection for hypertension, a chronic left knee disability, Eustachian tube dysfunction with subsequent intermittent hearing loss, a chronic lung disability, a chronic back disability, and a chronic left elbow disability. The same rating decision established service connection for the following disabilities: hemorrhoids, assigned a noncompensable rating under Diagnostic Code 7336; a history of vaginitis, assigned a noncompensable rating under Diagnostic Code 7611; bunion of the left foot, assigned a noncompensable evaluation under Diagnostic Code 5280; and an ingrown toenail, left great toe, with a history of fungal infection of the toenail, assigned a noncompensable evaluation under Diagnostic Code 7899-7813. The above rating decision also denied entitlement to a combined rating of 10 percent under the provisions of 38 C.F.R. § 3.324. In addition, entitlement to service connection for pyelonephritis was denied in the February 1994 rating decision. In her notice of disagreement (NOD), the veteran claimed that her kidney and pelvic problems were caused by her service-connected recurrent urinary tract infections. However, the RO did not address the claim in the statement of the case or in the supplemental statement of the case. Since the claim for service connection for pyelonephritis, to include the issue of entitlement to service connection secondary to recurrent urinary tract infections, is not inextricably intertwined with the claim on appeal, it is referred to the RO for appropriate action. For reasons set forth in the REMAND appended to this decision, appellate review is deferred regarding the claims of entitlement to service connection for Eustachian tube dysfunction with hearing loss, entitlement to service connection for hypertension, entitlement to a compensable rating for service-connected hemorrhoids, entitlement to a compensable rating for service-connected vaginitis, and entitlement to a 10 percent rating under the provisions of 38 C.F.R. § 3.324 for separate noncompensable service- connected disabilities, from October 1, 1992, to April 15, 1994. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends that service connection should be established for each of the claimed disabilities for which it has not yet been established. In addition, she claims that compensable evaluations should be assigned for the service- connected disabilities that are on appeal. Relating to her claimed hypertension, the veteran contends that she currently has hypertension for which she has been prescribed medication. The veteran claims that service connection should be granted for a left knee condition, since she complained about the condition during active service and continues to have pain, which is not constant but which occurs on exposure to cold weather and when standing or sitting for any length of time. See VA Form 9 (substantive appeal). In addition, the veteran claims that her service-connected bunion and ingrown toenail disabilities warrant compensable evaluations, since they cause her constant pain. She claims that she has constant coughing spells, and has been diagnosed with bronchitis. She claims to experience back pain distinct from her urinary infections, and that service connection should be granted on an independent basis. Relating to her left elbow condition, she claims that she continues to experience pain with movement of the elbow and upon lifting objects, and swelling and popping, and that service connection accordingly should be granted. See VA Form 9 (substantive appeal). DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991 & Supp. 1996), has reviewed and considered all of the evidence and material of record in the veteran's claims file. Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that the veteran has failed to satisfy the initial burden of submitting evidence sufficient to justify a belief by a fair and impartial individual that her claims for service connection for a chronic left knee disability, a chronic lung disability, a chronic back disability, and a chronic left elbow disability, are well grounded. Furthermore, it is the decision of the Board that the preponderance of the evidence is against compensable evaluations for her service-connected bunion of the left foot and her service-connected ingrown toenail of the left great toe, with a history of fungal infection. FINDINGS OF FACT 1. The RO has obtained all relevant evidence necessary for an equitable disposition of the veteran’s claims for compensable ratings for a service-connected bunion of the left foot and ingrown toenail of the left great toe, with a history of fungal infection. 2. The veteran has not submitted competent medical evidence of a currently manifested chronic left knee disability. 3. The veteran has not submitted competent medical evidence of a currently manifested chronic lung disability. 4. The veteran has not submitted competent medical evidence of a currently manifested chronic back disability. 5. The veteran has not submitted competent medical evidence of a currently manifested chronic left elbow disability. 6. The veteran’s claims for service connection for a chronic left knee disability, a chronic lung disability, a chronic back disability, and a chronic left elbow disability, are not plausible. 7. The veteran’s bunion of the left foot is manifested by subjective complaints of intermittent pain, but which was doing well as reported on VA examination. The bunion has not received surgery, and is not productive of a severe condition that is equivalent to amputation of the great toe, nor is it productive of impairment analogous to a moderate foot injury. 8. The veteran’s ingrown toenail of the left great toe, with a history of fungal infection, is manifested by subjective complaints of constant pain, although these complaints were not indicated on VA examination. The disability is not productive of exfoliation, exudation or itching, involving an exposed surface or extensive area, nor is it productive of impairment analogous to a moderate foot injury. CONCLUSIONS OF LAW 1. The veteran has not submitted a well-grounded claim for a chronic left knee disability. 38 U.S.C.A. § 5107 (West 1991). 2. The veteran has not submitted a well-grounded claim for a chronic lung disability. 38 U.S.C.A. § 5107 (West 1991). 3. The veteran has not submitted a well-grounded claim for a chronic back disability. 38 U.S.C.A. § 5107 (West 1991). 4. The veteran has not submitted a well-grounded claim for a chronic left elbow disability. 38 U.S.C.A. § 5107 (West 1991). 5. The criteria for a compensable evaluation for a bunion of the left foot are not met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. § 4.71a, Diagnostic Code 5280 (1996). 6. The criteria for a compensable evaluation for an ingrown toenail of the left great toe, with a history of fungal infection, are not met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. § 4.118, Diagnostic Code 7899-7813 (1996). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Factual Background In the Report of Medical History completed by the veteran in connection with her entrance physical examination conducted in December 1975, she indicated no complaints of current or previous medical problems. In the physical examination report, no abnormality was found. Her blood pressure was measured as 110/70 (systolic/diastolic). In various treatment notations from June 1976 through April 1977, the veteran’s blood pressure measurements ranged from 98 to 130 systolic, and from 50 to 78 diastolic. In March 1977, the veteran complained of right low back pain, related to a diagnosis of a possible urinary tract infection. In a May 1977 treatment notation related to the veteran being nervous, her blood pressure was recorded as 120/90. In a notation entered one week later, her blood pressure was reported as 118/72. In May 1977, she underwent a chest x-ray as part of an annual physical. The x-ray was normal. In treatment notations from June 1977 through July 1977, her blood pressure ranged from 100 to 118 systolic, and from 60 to 64 diastolic. In an inpatient summary dated in October 1977 related to a period of hospitalization for acute pyelonephritis, it was noted that the veteran had low back pain. On physical examination, it was reported that she had mild right costovertebral angle tenderness, however, there were no musculoskeletal abnormalities indicated. In a March 1978 respiratory treatment notation, the veteran complained of dizziness and achiness, including low back pain and tenderness in the area of the kidneys. Her blood pressure was recorded as 110/58. The assessment was labyrinthitis and body aches, the etiology of both which was unknown. In a June 1978 treatment notation relating to an assessment of cystitis, it was noted that the veteran had lower back pain. No musculoskeletal problem was reported. In a treatment notation of August 1978, it was noted that the veteran had a headache and backache since the previous day. The veteran’s history of kidney problems was noted, and on objective examination, no increase in pain was manifest upon palpation. In treatment notations from September 1978 through January 1979, her blood pressure ranged from 104 to 120 systolic, and from 58 to 80 diastolic. In January 1979, the veteran complained of persistent back pain, and an inability to eat. On objective examination, it was noted that her back was normal, and that straight leg raising was negative. Her blood pressure was 100/70. In treatment notations from February 1979 through August 1979, the veteran’s blood pressure ranged from 90 to 128 systolic, and from 50 to 80 diastolic. In October 1979, she complained of low back pain in addition to other genitourinary symptoms. On examination of the back, there was no muscle spasm reported, and the back was normal. The impression was a questionable urinary tract infection, and a questionable muscular condition. Her blood pressure was 100/70, and was the same in a notation entered three days later. In April 1980, the veteran’s blood pressure was reported as 110/82. In May 1980, the veteran complained of cold symptoms of three days’ duration, with a headache, runny nose, sore throat, and cough. The assessment was an upper respiratory infection. Her blood pressure was recorded as 120/96. In treatment notations of July 1980 and August 1980, her blood pressure was reported as 116/74 and 122/68, respectively. In an August 1980 medical statement, she indicated that she did not have a past history of high blood pressure or lung problems. On objective examination, her heart, lungs, and back were normal, and her blood pressure was measured as 122/68. In treatment notations from April 1981 through May 1981, the veteran’s blood pressure ranged from 110 to 112 systolic, and from 66 to 74 diastolic. In September 1981, she complained of a lower back ache with radiating pain into the right flank. The examiner found pain in the right flank on objective examination. The assessment was to rule out a urinary tract infection. During the examination, her blood pressure was recorded as 98/64. In treatment notations entered from November 1981 through June 1982, her blood pressure ranged from 98 to 122 systolic, and from 64 to 74 diastolic. In a Report of Medical History completed by the veteran in connection with a physical examination in September 1982, she indicated that she currently or previously had foot trouble. No other musculoskeletal problem, heart trouble or high or low blood pressure, or respiratory problem was indicated. The examiner noted that the veteran had an “ingrown toenail” of the left first toe for about one year. In the physical examination report, the examiner also noted that she had an ingrown toenail on the left first toe. No musculoskeletal abnormality, respiratory problem, or heart or vascular problem was reported. Her blood pressure while sitting was reported as 108/62. A contemporaneous chest x-ray was negative for any abnormality. In September 1982, the veteran was treated for an ingrown toenail of the left first toe, of one year's duration. In treatment notations from September 1982 through January 1983, her blood pressure ranged from 102 to 110 systolic, and from 60 to 84 diastolic. In January 1983, she was treated for slightly ingrown toenails of the great toes, with tenderness about the left great toe nail. At this time, her blood pressure was reported as 128/82. In a subsequent treatment notation of January 1983, her blood pressure was reported as 112/68. Also in January 1983, she complained of problems with her great nail. From May 1983 through June 1984, her blood pressure ranged from 94 to 130 systolic, and from 58 to 84 diastolic. In the Report of Medical History completed by the veteran in connection with a physical examination in June 1984, she indicated no past or present complaints of musculoskeletal problems, respiratory problems, or heart trouble or high or low blood pressure. On physical examination, her lungs and chest were normal, and there was no vascular abnormality, nor was there any musculoskeletal abnormality noted. Her blood pressure while sitting was 120/74. A contemporaneous chest x-ray was negative for any abnormality. In treatment notations from August 1984 through October 1985, the veteran’s blood pressure ranged from 104 to 132 systolic, and from 60 to 80 diastolic. In December 1985, the veteran was treated for an upper respiratory infection with bronchitis. Her blood pressure was reported as 116/78. In March 1986, she was treated for a bunion of the left foot. The assessment was hallux abducto valgus with bump pain. A contemporaneous x-ray noted the presence of hallux valgus and pes planus. In December 1986, her blood pressure was reported as 120/80, and in February 1987, her blood pressure was 124/88. In February 1987, the veteran was accorded an “over 40” physical examination. With the exception of foot trouble, she reported no musculoskeletal, respiratory, or heart or high blood pressure problems. On physical examination, her blood pressure was recorded as 132/82, and a chest x-ray was negative. In treatment notations from March 1987 through July 1987, the veteran’s blood pressure ranged from 100 to 120 systolic, and from 62 to 88 diastolic. In a December 1987 treatment notation, her blood pressure was reported as 150/90. In a subsequent notation entered six days later related to an impression of an upper respiratory infection/viral syndrome, her blood pressure was measured as 140/90. She was prescribed medication for her respiratory/viral condition, and advised to discontinue tobacco use. In treatment notations from January 1988 through February 1988, the veteran’s blood pressure ranged from 121 to 142 systolic, and from 78 to 86 diastolic. In a March 1988 examination report, the examiner noted that her lungs were clear, and there was no costovertebral angle tenderness of the back. Her blood pressure was 147/102. In March 1988, she was treated for complaints of sore big toenails. The impression was onycholysis and early ingrown nails. On examination, her blood pressure was reported as 140/91. In connection with a May 1988 “over 40” physical examination, the veteran reported that she had foot trouble. No other musculoskeletal problem was noted, and there was no report of respiratory problems, or heart trouble or high blood pressure. On physical examination, no abnormalities were reported. Her blood pressure while sitting was recorded as 100/60, and 133/78 on the same day. The veteran’s heart and lungs were normal on chest x-ray in June 1988. In June 1988, she presented with complaints of a swollen left arm and hand related to previously diagnosed cellulitis of the left hand following a wasp sting. Her blood pressure was reported as 142/88. In June 1988, the veteran underwent a graded exercise test. During the test, her blood pressure ranged from 102 to 170 systolic, and from 70 to 76 diastolic. The impression was a normal test, with good exercise tolerance. In treatment notations of August 1988, her blood pressure was reported as 123/59 and 119/89. In an undated treatment notation prepared in connection with a colonoscopy conducted when the veteran was 41 years old, her blood pressure was reported as 140/88 prior to the procedure, and 150/80 after the procedure. In a treatment notation of March 1989, the veteran’s blood pressure was reported as 120/80. In a subsequent notation of April 1989, her blood pressure was 140/90, and later in April 1989, her blood pressure was 120/80. In May 1989, she presented with complaints of back pain after lifting a heavy load at work. She complained of an inability to sleep due to the pain and discomfort, and also complained of dysuria and frequency. On physical examination, her back had a slightly asymmetrical deviation to the right, and there was a palpable spasm in the right paraspinal area in the T9 to T10 area and inferior to the scapula, without suprapubic tenderness to palpation. The examiner diagnosed urethral irritation and back pain. Her blood pressure was reported as 120/60. In treatment notations from March 1990 through August 1990, the veteran’s blood pressure ranged from 116 to 130 systolic, and from 60 to 84 diastolic. In an examination report of October 1990, her blood pressure was reported as 128/76, and her chest, lungs, and back were reported as normal. In treatment notations from January 1991 to August 1991, her blood pressure ranged from 110 to 120 systolic, and from 60 to 80 diastolic. In September 1991, the veteran complained of left knee pain and popping of the left knee. There was no effusion of the left knee, and range of motion was 180 - 35 degrees. There were negative drawer, Lachman’s McMurray’s, and apprehension tests. During the examination, her blood pressure was reported as 120/88. In October 1991, her blood pressure was reported as 130/60. In a treatment notation of November 1991, it was reported that she complained of frequent urination with low back pain of five days’ duration. Her blood pressure was reported as 130/80. In February 1992, the veteran complained of congestion of three weeks’ duration, and coughing up mucous. She had a runny nose, and her condition was exacerbated by cold air. The examiner noted that she felt nauseous when she went into coughing spells, and she suffered from headaches. She also had headaches and a right earache. It was noted that she smoked 1 pack of cigarettes a day for thirty years. The assessment was probable bronchitis. She was prescribed antibiotics and was advised to stop smoking. Her blood pressure was 130/80. In a treatment notation of March 1992, the examiner noted that the veteran did not have a past history of high blood pressure. Her blood pressure was 110/88. In April 1992, the veteran presented with complaints of pain in the left knee, foot, and toe. Her blood pressure was reported as 150/90, and on recheck was 142/94. She stated that the pain got worse whenever the weather got cold, or after extended walking. It was noted that she reported feeling like the knee was going to give way. There was no knee pain at the time of examination. On physical examination of the left knee, there was no swelling, discoloration, or point tenderness. There was a negative Lachman’s test, and slight anterior drawer sign. The knee was laterally stable. On examination of the left foot and toe, there was an ingrown toenail of the medial aspect of the left great toe, and enlargement on the left medial metatarsal phalangeal joint of the forefoot. The left great toenail was thickened with white crusting underneath. There was no erythema or swelling around the toenail. The assessment was left knee pain, left foot bunion, tinea unguium of the left great toenail, and elevated blood pressure. The veteran was placed on a five-day blood pressure check. In April 1992, the veteran’s blood pressure was measured eleven times over the course of six days. Systolic pressures ranged from 114 to 160 for the left arm, and from 120 to 160 for the right arm. Diastolic pressures ranged from 72 to 112 for the left arm, including three measurements with diastolic pressures over 100, and from 70 to 112 for the right arm, including four measurements with diastolic pressures over 100. The blood pressure measurements were averaged by the examining physician, and were reported as 135/87 for the left arm, and 141/90 for the right arm. In the April 1992 follow-up treatment notation, it was noted that her blood pressure was 140/100. The assessment was borderline hypertension, and a low salt diet was recommended, as was stress reduction and smoking cessation. In April 1992, the veteran was seen for a left foot bunion. The examiner noted that the veteran had onychauxis, onychocryptosis of the left hallux, and mild hallux valgus of the left foot. In a June 1992 treatment notation, the examiner noted that the veteran complained of pain of the bunion on the medial side of the left foot, and a partial ingrown toenail of the left big toe. Her blood pressure was recorded as 100/86, 130/80 while recumbent, and 126/90 while standing. It was noted that she was scheduled to undergo surgery on the bunion, but that the surgery was not performed due to scheduling problems. On objective examination, it was noted that she had a hallux valgus of the left foot. She had full active range of motion, 5/5 muscle strength, deep tendon reflexes were 2+ bilaterally, neuro/vascular was intact, and there was no erythema or edema. The assessment was left hallux valgus. In a podiatry consultation of July 1992, it was reported that the veteran had moderate hallux valgus/bunion of the left foot. In a July 1992 gynecological evaluation form, the veteran indicated that she had a history of high blood pressure. It was noted that the need to quit smoking was discussed. In an undated gynecological evaluation form completed when the veteran was age 45, she indicated that she had a history of high blood pressure. The veteran underwent a physical examination in July 1992. In the Report of Medical History, she indicated that she currently or previously had swollen or painful joints, shortness of breath, high or low blood pressure, arthritis, rheumatism, or bursitis, and foot trouble. No other musculoskeletal or respiratory abnormality was noted. However, she indicated that she did not currently or previously have a painful or “trick” shoulder or elbow. In an attached sheet, she indicated that her knee was swollen and she had pain in her joints. She complained of shortness of breath when running, and that she was monitored for high blood pressure. She also indicated that she had a bunion on her left foot and a problem with her toe nail. The examining physician noted that the veteran reported doing well except for left knee pain, a left bunion, and a history of labile hypertension. The physical examination was normal except for a bunion of a left foot and an abnormality of the right ear. Her blood pressure while sitting was 148/100, and a three-day blood pressure re-check was ordered, as it was “borderline.” The examiner noted that the veteran had left knee pain, a left bunion, elevated cholesterol, and borderline blood pressure. A contemporaneous chest x-ray was normal. In July 1992, the veteran underwent a five day blood pressure check. The initial measurement was 148/100. Subsequent measurements while sitting were 142/90, 148/98, and 144/82 on the first day, and 130/72 on the second day. There were no measurements for any other days. In a treatment notation of August 1992, the veteran complained of pain in the left knee, left upper arm, and left large toe area for two weeks. The examiner deferred an examination, and indicated an assessment of a bunion and chronic knee pain. Her blood pressure was 130/80. On VA general medical examination in July 1993, the examiner noted that the veteran reported being told that she had high blood pressure while she was in active service. The veteran stated that she never took any medications for the condition, and she had not seen another physician to confirm whether her blood pressure was elevated or not. She also complained of low back pain after standing for approximately thirty minutes. There was no history of trauma or paralysis of the arms or legs, and she was seen by an Army physician for the problem but no medications were prescribed. She complained of left knee pain and left elbow pain, which occurred during cold weather or when it rained. There was no history of trauma, fractures, or arthritis. She indicated that she had a bunion on her left big toe. On physical examination, the examiner reported that her blood pressure was 136/70. The veteran’s lungs were clear. Her left elbow showed full range of motion, with no tenderness and no soft tissue swelling. The back was nontender and straight leg raising was negative. The left knee showed full range of motion with no soft tissue swelling or effusion, and the ligaments were stable. The examiner noted that the left big toe showed a bony bunion. The impression included a history of low back pain and left knee and elbow pain. On VA examination of the joints in July 1993, the examiner noted that the veteran had no recollection of a back injury, and there was no definitive diagnosis according to her history. The examiner reported that the veteran underwent conservative treatment for back pain during active service. The veteran complained of increased pain with prolonged sitting or standing, but presently was asymptomatic. The examiner reported that there was no history of a left knee injury, and the veteran described intermittent pain in the knee exacerbated by raining or cold weather. There was no diagnosis of any specific left knee problems, and she presently was asymptomatic. The examiner noted that the history of the claimed left elbow disability was similar to the claimed left knee condition, and that she presently was asymptomatic. The examiner also reported that the veteran had a history of a bunion which was intermittently painful, with pain that was intensified by wearing combat boots during active service. She was presently doing well. On physical examination, the examiner noted that the veteran walked with an unremarkable gait pattern. Examination of the left elbow revealed 0 to 150 degrees range of motion, and some popping on range of motion of the elbow was noted. No redness, heat, swelling, or tenderness was noted. Examination of the back revealed that she was able to stand erect, and there was no evidence of spasm or tenderness. Range of motion of the lumbar spine was 80 degrees of flexion and 30 degrees of extension, and there was no pain on motion noted. The left knee had 0 to 140 degrees range of motion, and there was no redness, heat, swelling, tenderness, or instability noted, and there was no pain on motion. Examination of the left foot revealed a bunion of the left great toe, and there was no tenderness to palpation noted and there was full range of motion present. The veteran performed a satisfactory heel and toe walk and was able to squat and arise again. Reflexes and sensation were intact in the lower extremities. The impression was comprised of the following: bunion of the left foot; history of recurrent low back syndrome, presently asymptomatic, with present examination unremarkable; history of recurrent left elbow pain, presently asymptomatic, with present examination unremarkable; history of recurrent left knee pain, presently asymptomatic, with present examination unremarkable. X-rays of the lumbar spine, the left elbow, and the left knee were normal. Although one was ordered, an x-ray of the left foot is not contained in the claims folder. The claims folder contains private records from the University of Alabama dating from July 1993 to February 1994. The treatment records include the following blood pressure measurements: 118/70 in November 1993; and 120/80 in February 1994. In the report of a November 1994 VA fee-basis gynecological examination, the veteran’s blood pressure was measured as 180/100. The claims folder contains VA medical records dating from October 1993 to October 1994. The records include a treatment notation made in October 1993, after the veteran had undergone surgery for a gynecological problem. In the notation, the examining physician noted that the veteran required referral to her primary care physician for further evaluation and treatment for her hypertension. The physician noted that the hypertension was unrelated to anesthesia or surgery. After medication, the veteran’s blood pressure was 140/90. In a treatment notation of November 1993, the examiner noted that the veteran was in for a blood pressure check. The veteran was on no medications, and had no headaches or epistaxis. Her blood pressure was checked by the nurse, and it was 192/108 for the left arm, and 178/108 for the right arm. The examining physician checked again, and her blood pressure was 160/80. The veteran explained that she was under stress. The impression was labile blood pressure, possibly stress induced. The plan included a laboratory test, but the veteran left without getting it done. In a treatment notation of May 1994, the veteran’s blood pressure was reported as 135/92. In a June 1994 treatment notation, her blood pressure was reported as 152/92. In July 1994, her blood pressure was reported as 146/80, and in a notation entered later in the month, her blood pressure was reported as 152/86. In a treatment notation of October 1994, it was reported that the veteran’s blood pressure was 180/100 for the left arm, while sitting. On objective examination, the examiner noted that her chest showed inspiratory wheezes in bases bilaterally posteriorly. The assessment included elevated blood pressure, possibly labile, bronchitis, and tobacco abuse. A recheck revealed a blood pressure for the right arm, while sitting, of 170/90. II. Analysis Entitlement to service connection for a chronic left knee disability, a chronic lung disability, a chronic back disability, and a chronic left elbow disability 1. Well-groundedness Initially, it is necessary to determine if the veteran has submitted well-grounded claims within the meaning of 38 U.S.C.A. § 5107(a) (West 1991). That same statute mandates a duty to assist the veteran. However, the duty to assist applies only after a well-grounded claim has been submitted. Gilbert v. Derwinski, 1 Vet.App. 49, 55 (1990). In making a claim for service connection, the veteran has the burden of submitting evidence sufficient to justify a belief by a fair and impartial individual that the claim is well grounded. 38 U.S.C.A. § 5107(a) (West 1991). Generally, a well-grounded claim is “a plausible claim, one which is meritorious on its own or capable of substantiation.” Murphy v. Derwinski, 1 Vet.App. 78, 81 (1990). In order to be well grounded, a claim for service connection must be accompanied by supporting evidence that the particular disease, injury, or disability was incurred in or was aggravated by active service; mere allegations are insufficient. Tirpak v. Derwinski, 2 Vet.App. 609, 610-611 (1992); Murphy v. Derwinski, 1 Vet.App. at 81. The quality and quantity of evidence required to make a claim well grounded depend upon the issue presented by the claim. When an issue is factual in nature (e.g., whether an incident or injury occurred in service), competent lay testimony, including the appellant’s solitary testimony, may be sufficient to meet the veteran’s burden. Grottveit v. Brown, 5 Vet.App. 91, 93 (1993) (citing Cartright v. Derwinski, 2 Vet.App. 24 (1991)). Where the determinative issue, however, concerns matters of medical causation or diagnoses, competent medical evidence attesting that the claim is plausible or possible is required. Grottveit v. Brown, 5 Vet.App. at 93 (citing Murphy v. Derwinski, 1 Vet.App. at 81). Service connection means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated during service. 38 U.S.C.A. §§ 1110, 1131 (West 1991); 38 C.F.R. § 3.303(a) (1996). The evidence may show affirmatively that such a disease or injury was incurred in or aggravated by service, or statutory presumptions may be applied to establish service connection. With chronic disease shown as such in service or within the presumptive period so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b) (1996). A claim for service connection requires three elements to be well grounded. It requires competent (medical) evidence of a current disability; competent (lay or medical) evidence of incurrence or aggravation of disease or injury in service; and competent (medical) evidence of a nexus between the in- service injury or disease and the current disability. The third element may be established by the use of statutory presumptions. Caluza v. Brown, 7 Vet.App. 498, 506 (1995), aff’d 78 F.3d 604 (Fed. Cir. 1996) (table). Truthfulness of the evidence is presumed in determining whether a claim is well grounded. Caluza v. Brown, 7 Vet.App. at 504. In Brammer v. Derwinski, 3 Vet.App. 223, 225 (1992), the Court noted that “Congress specifically limits entitlement to service-connected disease or injury to cases where such incidents have resulted in a disability....In the absence of proof of a present disability there can be no valid claim.” 2. Review of claims on appeal a. Entitlement to service connection for a chronic left knee disability The veteran’s service medical records document treatment on several occasions for pain in the left knee, which was exacerbated by cold weather or extended walking. On separation physical examination in July 1992, the examiner noted that the veteran had left knee pain, and left knee pain was noted on examination in August 1992. However, in the report of the VA general medical examination of July 1993, it was reported that her left knee showed full range of motion with no soft tissue swelling or effusion, and the ligaments were stable. The impression included a history of left knee pain. On VA examination of the joints, also conducted in July 1993, the examiner described the veteran’s complaints of intermittent pain in the knee exacerbated by raining or cold weather. However, the impression was comprised of a history of recurrent left knee pain, presently asymptomatic, with the present examination unremarkable. X-rays of the left knee were normal. Although the veteran’s separation physical examination, and the VA examination conducted in July 1993 reported a diagnostic impression of a history of left knee pain, no chronic disability was found on objective examination or on x-ray analysis. The subsequent VA and private medical records fail to indicate any current treatment or diagnosis of a left knee disability. Since there is no medical evidence of a currently manifested chronic left knee disability, service connection must be denied. See Brammer v. Derwinski, 3 Vet.App. 223, 225 (1992). Accordingly, the veteran’s claim of entitlement to service connection for a chronic left knee disability is not plausible. b. Entitlement to service connection for a chronic lung disability The veteran’s service medical records, including chest x-rays conducted during active service, do not indicate any chronic lung disorder or other respiratory abnormality. While her service medical records do show that she was diagnosed with probable bronchitis in February 1992, at which time she was prescribed antibiotics and advised to stop smoking, no chronic disorder was diagnosed. On separation physical examination in July 1992, she complained of shortness of breath when running. Again, neither chronic bronchitis nor any other chronic respiratory problem was diagnosed. On VA general medical examination in July 1992, her lungs were clear. Although the claims folder contains VA outpatient treatment reports showing that the veteran was diagnosed with bronchitis in October 1994, there is no evidence that the veteran has bronchitis or any other lung disorder as a chronic condition which may be related to her active service. Since there is no medical evidence of a currently manifested chronic lung disability, service connection must be denied. See Brammer v. Derwinski, 3 Vet.App. 223, 225 (1992). Accordingly, the veteran’s claim of entitlement to service connection for a chronic lung disability is not plausible. c. Entitlement to service connection for a chronic back disability The veteran’s service medical records show treatment for lower back pain on various occasions, which was primarily associated with genitourinary problems. In May 1989, she complained of back pain after lifting a heavy load at work. The examiner diagnosed back pain. There was no further treatment for back pain noted, and on separation examination in July 1992, no back problem was indicated. The current medical evidence pertaining to the veteran’s claimed low back disorder is comprised of the reports of the VA general medical and joints examinations conducted in July 1993. In the report of the general medical examination, the examiner noted the veteran’s complaints of low back pain after standing for approximately thirty minutes. However, on objective examination, the back was nontender and straight leg raising was negative. The impression was a history of low back pain. On VA examination of the joints, the examiner noted the veteran’s conservative treatment for back pain during active service. While she complained of increased pain with prolonged sitting or standing, she presently was asymptomatic. She walked with an unremarkable gait, she was able to stand erect, and there was no evidence of spasm or tenderness. Although the veteran’s forward flexion was less than full at 80 degrees, there was no pain on motion, and x- rays showed no fracture or dislocation. The examiner found the veteran asymptomatic. Since there is no medical evidence of a currently manifested chronic back disability, service connection must be denied. See Brammer v. Derwinski, 3 Vet.App. 223, 225 (1992). Accordingly, the veteran’s claim of entitlement to service connection for a chronic back disability is not plausible. d. Entitlement to service connection for a chronic left elbow disability Although the veteran indicated in the Report of Medical History completed in connection with her separation physical examination that she currently or previously had swollen or painful joints, she did not indicate that she ever had problems with her elbow. In fact, she specifically noted that she did not currently or previously have a painful or “trick” shoulder or elbow. No elbow problem was diagnosed, and the remainder of the service medical records do not refer to treatment for a left elbow disorder. On VA general medical examination in July 1993, the veteran’s left elbow showed full range of motion, with no tenderness or soft tissue swelling. The impression included a history of left elbow pain, however, no currently manifested abnormality was indicated. In the report of the VA examination of the joints in July 1993, the examiner noted that the veteran currently was asymptomatic. Range of motion examination showed 0 to 150 degrees range of motion, with some popping of the elbow noted. The impression was of history of recurrent left elbow pain, presently asymptomatic, with present examination unremarkable. X-rays showed no significant abnormality. Since there is no medical evidence of a currently manifested left elbow disorder, service connection must be denied. See Brammer v. Derwinski, 3 Vet.App. 223, 225 (1992). Accordingly, the veteran’s claim of entitlement to service connection for a chronic left elbow disability is not plausible. 3. Notice The Board notes that the United States Court of Veterans Appeals (Court) has held that, when a claimant fails to submit a well-grounded claim under 38 U.S.C.A. § 5107(a) (West 1991), VA has a duty to advise the claimant of the evidence required to complete the application. 38 U.S.C.A. § 5103(a) (West 1991); Robinette v. Brown, 8 Vet.App. 69, 77- 80 (1995). In this case, the Board finds that this procedural consideration already has been satisfied. The RO fulfilled its procedural obligations under § 5103(a) by informing the veteran of the reason for its denial of service connection, in the rating decision on appeal and in the statement of the case (SOC). In addition, this Board decision informs the veteran of the evidence that is lacking to make her claims well grounded. Although the RO did not notify the veteran, in the rating decision that is the subject of this appeal, that her claims were not well grounded, any such error was nonprejudicial. See Edenfield v. Brown, 8 Vet.App. 384 (1995) (“Assuming, arguendo, that it was error to express a disallowance in terms of the merits where the claim is, in fact and law, not well grounded, the Court should nonetheless affirm the Board’s ‘erroneous’ disallowance of the claim on the merits unless to do so would prejudice the appellant.” [Citations omitted]). In this case, any such error by the RO was nonprejudicial, since the rating decision on appeal and the SOC provided the reasons and bases for the RO’s denial. In March 1997, the veteran’s representative cited provisions of the VA Adjudication Procedure Manual M21-1 (M21-1), specifically, Part III, Paragraph 1.03a, and Part VI, Paragraph 2.10f. The representative requested that “[i]f the Board finds that [the veteran’s] current claim is not well grounded. . . that the Board determine whether the RO followed the M21-1 substantive rules requiring that full development of all claims be undertaken prior to the well grounded determination.” The representative has requested that if the Board finds that such development in accordance with M21-1 did not occur, then the case should be remanded for full development of the claim. The representative also requested that in the Board’s remand order, the RO be directed to notify the veteran of the one year time limit to produce evidence in accordance with 38 U.S.C.A. § 5103(a). See Written Brief Presentation, March 10, 1997, at 3. In addressing these contentions, the Board notes that the RO developed the veteran’s claim in accordance with the provisions of M21-1, by affording the veteran a VA general medical examination and a VA examination of the joints. The veteran has not put VA on notice of the existence of any specific, particular piece of evidence that, if submitted, could make her claims well grounded. Because she has not submitted a well-grounded claim, VA does not yet have a duty to assist her in developing the claim pursuant to 38 U.S.C.A. § 5107(a). C. Entitlement to a compensable rating for service-connected bunion of the left foot, and a compensable rating for service-connected ingrown toenail, left great toe, with a history of fungal infection 1. Well-groundedness determination The veteran has presented well-grounded claims for compensable disability ratings for her service-connected bunion of the left foot and for her service-connected left toenail disability within the meaning of 38 U.S.C.A. § 5107(a) (West 1991). See Shipwash v. Brown, 8 Vet.App. 218, 224 (1995) (When a claimant appeals the RO’s initial assignment of a disability rating when service connection was established, the claim continues to be well grounded as long as the rating schedule provides for a higher rating and the claim remains open). Since the veteran has presented well-grounded claims, VA has a statutory duty to assist her in developing the facts pertinent to her claim. Littke v. Derwinski, 1 Vet.App. 90 (1990). In this case, the RO afforded the veteran a VA general medical examination and VA examination of the joints. Sufficient evidence is of record for an equitable disposition of the appeal. 2. Increased disability evaluations Disability ratings are intended to compensate reductions in earning capacity as a result of a specific disorder or combinations of disorders. The ratings are intended, as far as practicably can be determined, to compensate the average impairment of earning capacity resulting from such disorder(s) in civilian occupations. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (1996). The law requires that where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (1996). While evaluation of a service-connected disability requires a review of the veteran’s medical history with regard to that disorder, the United States Court of Veterans Appeals (Court) has held that, where entitlement to compensation has already been established, and an increase in the disability rating is at issue, the present level of disability is of primary concern. See Francisco v. Brown, 7 Vet.App. 55, 58 (1994); Peyton v. Derwinski, 1 Vet.App. 282 (1991); 38 C.F.R. §§ 4.1, 4.2 (1996). a. Entitlement to a compensable rating for a service- connected bunion of the left foot The veteran’s service-connected bunion of the left foot is rated pursuant to Diagnostic Code 5280 of the VA Schedule for Rating Disabilities, 38 C.F.R. Part 4 (1996) (Schedule). Diagnostic Code 5280 relates to hallux valgus, unilateral. Utilizing the diagnostic criteria, a 10 percent evaluation is assigned when the condition has undergone operation, with resection of the metatarsal head. A 10 percent evaluation also is assigned for a severe condition, if equivalent to amputation of the great toe. 38 C.F.R. § 4.71a, Diagnostic Code 5280 (1996). Since VA has a duty to consider all potentially applicable regulations, to include appropriate diagnostic codes, additional diagnostic codes will be reviewed. Diagnostic Code 5281 relates to unilateral hallux rigidus, severe, which is rated as hallux valgus, severe, under Diagnostic Code 5280. 38 C.F.R. § 4.71a, Diagnostic Code 5281 (1996). Diagnostic Code 5284 relates to other foot injuries. Utilizing the diagnostic criteria, moderate foot injuries are rated as 10 percent disabling, a moderately severe condition warrants a 20 percent evaluation, and a severe condition warrants the assignment of a 30 percent evaluation. Under the diagnostic code, a 40 percent evaluation is assigned when there is actual loss of the foot. 38 C.F.R. § 4.71a, Diagnostic Code 5284 (1996). The evidence shows that the veteran’s service-connected bunion of the left foot does not warrant assignment of a compensable evaluation. In the report of the VA examination of the joints conducted in July 1993, the examiner noted that the veteran had a history of a bunion which was intermittently painful, and which was exacerbated particularly by wearing combat boots during active service. However, the examiner noted that she was doing well presently. On objective examination of the left foot, a bunion of the left great toe was noted, however, there was no tenderness to palpation and there was full range of motion present. She was able to perform a satisfactory heel and toe walk. Although the examiner ordered an x-ray of the left foot, which is not contained in the claims folder, the Board finds that the examination report provides an adequate evaluation of the veteran’s foot disability such that the Board may rate it. The medical evidence does not show that surgery was performed on the veteran’s bunion. Furthermore, the evidence does not demonstrate that the bunion is productive of a severe disability that would warrant assignment of a compensable evaluation under Diagnostic Code 5280, or is productive of impairment analogous to a disability rated under Diagnostic Code 5281 or to a moderate foot injury rated under Diagnostic Code 5284. 38 C.F.R. § 4.71a, Diagnostic Codes 5280, 5281, 5284 (1996). In view of the foregoing, the Board concludes that the impairment resulting from the veteran’s service-connected bunion of the left foot does not meet the criteria for assignment of a compensable evaluation. 38 C.F.R. § 4.7, 4.71a, Diagnostic Codes 5280, 5284 (1996). The preponderance of the evidence being against the veteran’s claim, the benefit of the doubt rule enunciated in 38 U.S.C.A. § 5107(b) is not for application. b. Entitlement to a compensable rating for a service- connected ingrown toenail of the left great toe, with a history of fungal infection The veteran’s service-connected ingrown toenail of the left great toe, with a history of fungal infection, has been rated pursuant to Diagnostic Code 7899-7813 of the Schedule. This diagnostic code has been “built up” by using Diagnostic Code 7899 and rating by analogy to Diagnostic Code 7813. See 38 C.F.R. §§ 4.20, 4.27 (1996) (Guidelines concerning rating by analogy and the use of diagnostic code numbers). Diagnostic Code 7813 relates to dermatophytosis. As detailed in the Schedule, dermatophytosis is rated utilizing the same criteria as for eczema, dependent on location, extent, and repugnant or otherwise disabling character of manifestations. 38 C.F.R. § 4.118, Diagnostic Code 7819 (1996). Utilizing the diagnostic criteria for eczema, a noncompensable evaluation is assigned if there is slight, if any, exfoliation, exudation or itching, if on a nonexposed surface or small area. A 10 percent evaluation is warranted if there is exfoliation, exudation or itching, if involving an exposed surface or extensive area. A 30 percent evaluation is assigned if there is constant exudation or itching, extensive lesions, or marked disfigurement. Finally, a 50 percent evaluation is assigned in cases involving ulceration or extensive exfoliation or crusting, and systemic or nervous manifestations, or if the condition is exceptionally repugnant. 38 C.F.R. § 4.118, Diagnostic Code 7806 (1996). The evidence does not show that the veteran’s service- connected toenail disability warrants a compensable evaluation. The current medical evidence, comprised of the VA examinations of July 1993, and subsequent private and VA treatment records, make no reference to any toenail disability, to include a skin condition. In addition, her separation physical examination in July 1992 reported no toenail abnormality, although the veteran noted her difficulties in the Report of Medical History completed in connection with the examination. There is no medical evidence that the veteran’s condition is productive of exfoliation, exudation, or itching, involving an exposed surface or extensive area, required for a compensable evaluation under Diagnostic Code 7806. Furthermore, the Board finds that the toenail condition is not productive of impairment analogous to a moderate foot injury detailed in Diagnostic Code 5284. 38 C.F.R. § 4.71a, Diagnostic Code 5284, § 4.118, Diagnostic Code 7899-7813 (1996). In view of the foregoing, the Board concludes that the impairment resulting from the veteran’s service-connected ingrown toenail of the left great toe with a history of fungal infection does not meet the criteria for assignment of a compensable evaluation. 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Codes 5284, 4.118, Diagnostic Code 7899-7813 (1996). The preponderance of the evidence being against the veteran’s claim, the benefit of the doubt rule enunciated in 38 U.S.C.A. § 5107(b) is not for application. ORDER Having found the claim not well grounded, the claim of entitlement to service connection for a chronic left knee disability is denied. Having found the claim not well grounded, the claim of entitlement to service connection for a chronic lung disability is denied. Having found the claim not well grounded, the claim of entitlement to service connection for a chronic back disability is denied. Having found the claim not well grounded, the claim of entitlement to service connection for a chronic left elbow disability is denied. Entitlement to a compensable rating for a service-connected bunion of the left foot is denied. Entitlement to a compensable rating for a service connected ingrown toenail of the left foot, with a history of fungal infection, is denied. REMAND I. Entitlement to service connection for Eustachian tube dysfunction with hearing loss The veteran’s service medical records show that she was treated in December 1987 for otitis media. Other service medical records show that on audiometric examination in May 1988, she had pure tone threshold decibel loss for the right ear of 35, 20, 30, 10, and 40 decibels, at 500, 1000, 2000, 3000, and 4000 Hertz, respectively. Although not dispositive to whether service connection should be granted, this degree of hearing loss meets VA requirements for a disabling hearing loss as set forth in 38 C.F.R. § 3.385 (1996). The service medical records also show that on audiometric examination in July 1992, it was noted that the veteran was routinely exposed to hazardous noise. In the VA audio-ear disease examination in June 1993, the examiner noted that the veteran complained of decreased hearing on the right side, and found Eustachian tube dysfunction with subsequent intermittent hearing loss status post parotidectomy, no sequelae. Because the service medical records show that the veteran experienced some degree of hearing loss during active service, was routinely exposed to hazardous noise, and currently complains of decreased hearing in the right ear, this case will be REMANDED so that the veteran may be afforded a comprehensive VA audiological examination, including an audiogram, so that the nature, severity, and if possible, the etiology of any currently manifested ear problems, to include hearing loss, may be determined. II. Entitlement to compensable ratings for service-connected hemorrhoids and service-connected vaginitis VA outpatient treatment records contained in the claims folder show that the veteran sought treatment for problems associated with her service-connected hemorrhoids and service-connected vaginitis between May 1994 and October 1994. However, these records appear incomplete, since the treatment records were only photocopied on one side of the page, and a reverse side was indicated. Because the above treatment records may be relevant in evaluating the severity of the veteran’s hemorrhoids and vaginitis disabilities, VA has an obligation to obtain them. See Bell v. Derwinski, 2 Vet.App. 611, 613 (1992) (VA medical records are in constructive possession of the Secretary and the Board, and must be obtained if the material could be determinative of the claim). The veteran should also be afforded rectal and gynecological examinations in order to fully evaluate the current degree of severity of the veteran’s hemorrhoids and vaginitis. Therefore, the Board will REMAND this case so that the RO may obtain complete VA treatment records, as well as appropriate examinations. III. Entitlement to a 10 percent rating under the provisions of 38 C.F.R. § 3.324 for separate noncompensable service- connected disabilities, from October 1, 1992, to April 15, 1994 A. The Board’s jurisdiction over the claim The rating decision on appeal denied entitlement to a combined rating of 10 percent under the provisions of 38 C.F.R. § 3.324, for separate noncompensable service- connected disabilities. While the veteran generally referenced entitlement to a compensable evaluation for her service-connected disabilities in her notice of disagreement (NOD), the statement of the case (SOC) did not address the issue. During the pendency of this appeal, service connection was established for an additional disability which is not currently on appeal, to which a 10 percent disability evaluation was assigned effective April 15, 1994. Because a compensable evaluation pursuant to 38 C.F.R. § 3.324 may not be combined with any other rating, the RO listed as an issue in the supplemental statement of the case (SSOC), entitlement to a compensable rating pursuant to 38 C.F.R. § 3.324 from October 1, 1992, the effective date of the veteran’s service- connected disabilities, through April 15, 1994, the effective date of the 10 percent evaluation. The question arises whether this claim has properly been developed for appeal. Because this claim, as currently framed, regards entitlement to a compensable evaluation under § 3.324 for a specified period of time, which is a different issue than the issue as originally framed, the Board will interpret the SSOC as the original notice of nonentitlement to this benefit. Accordingly, the veteran had one year from the date of the SSOC, January 1995, in which to file a NOD to begin the appeal process. In May 1995, the veteran’s representative indicated an evaluation under § 3.324 as an issue on appeal. While this correspondence may be properly accepted as a NOD, the claim was not further developed for appeal by the RO. Although this claim may not have been properly developed for appeal by the RO, the Board nonetheless may take jurisdiction of the issue, as entitlement to a compensable evaluation under 38 C.F.R. § 3.324 may be interpreted to be a “subissue” of the claims for compensable evaluations of each individual disability, within the meaning of Bernard v. Brown, 4 Vet.App. 384 (1993) and VAOPGCPREC 16-92 (1992). Cf. VAOPGCPREC 6-96 (1996) at 9 (Entitlement to extraschedular evaluation under 38 C.F.R. § 3.321(b)(1) or entitlement to a total disability rating based on individual unemployability may be considered a component of an appealed increased rating case). The Board finds that there would be no due process problem with taking jurisdiction of this issue, since the veteran was advised of the applicable regulation in the SSOC, and the veteran’s representative specifically addressed the claims in its submittals. B. Review of claim Because the issue of entitlement to a compensable evaluation pursuant to 38 C.F.R. § 3.324 may be affected by the claims for compensable ratings that are the subject of this REMAND, the Board finds that it is inextricably intertwined with the other remanded claims. Accordingly, the Board will REMAND this claim pending further development of the remanded claims. Accordingly, this claim is REMANDED for the following: 1. Obtain and associate with the claims folder all examination and treatment reports dating from October 1992 to the present from the VA Outpatient Clinic in Huntsville, Alabama, relating to treatment for hemorrhoids, vaginitis, and ear problems, to include hearing loss. Attention should be paid to ensure that both sides of all treatment reports are photocopied and associated with the claims folder. 2. Ask the veteran if she has received any further treatment from private or VA health care providers for hemorrhoids, vaginitis, and ear problems, to include hearing loss. If so, obtain appropriate releases and obtain the treatment records. Associate all records received with the claims folder. 3. The veteran should be afforded a comprehensive VA audiological examination, including an audiogram, to determine the nature and severity of any currently manifested Eustachian tube dysfunction with hearing loss. The veteran’s claims folder is to be made available to the examiner to review prior to the examination, and the examiner is asked to indicate in the examination report that he or she has examined the claims folder. All tests deemed necessary by the examiner should be conducted, and the examiner should review the results of any testing prior to the completion of the examination report. The examiner should be asked to comment specifically on the following: a. Does the veteran currently suffer from Eustachian tube dysfunction with hearing loss? b. If hearing loss is shown, is it sensorineural or conductive type hearing loss? c. If hearing loss currently is shown, the examiner should identify the approximate date of onset, and detail the history of the condition as thoroughly as possible. Was sensorineural hearing loss manifest within one year of the veteran’s separation from service? A complete rationale for any opinion expressed must be provided. The report of the above-requested examination should be associated with the veteran’s claims folder. 4. The RO should afford the veteran VA rectal and gynecological examinations in order to fully evaluate the service- connected hemorrhoids and vaginitis. It should be indicated if the hemorrhoids are large or thrombotic, irreducible, with excessive redundant tissue, evidencing frequent recurrences. The gynecological examiner should fully describe the degree of severity of the service-connected vaginitis. All indicated special studies deemed necessary should be accomplished. The claims folder must be made available to the examiners prior to the examinations so that the veteran’s entire medical history can be taken into consideration. 5. The RO should afford the veteran a special VA cardiovascular examination. Specifically, she should be afforded a five day blood pressure check. Once this check has been completed, and following a review of the claims folder, to include the service medical records, the examiner should render a definitive diagnosis. In other words, it should be ascertained whether she suffers from essential hypertension. If essential hypertension is found, an opinion should be rendered as to whether this condition manifested itself during active duty. All indicated special studies deemed necessary should be accomplished. The claims folder must be made available to the examiner prior to the examination so that the veteran’s entire medical history can be taken into consideration. 6. Following completion of the foregoing, the RO must review the claims folder and ensure that all required development actions have been conducted and completed in full. If any development is incomplete, appropriate corrective action is to be implemented. Specific attention is directed to the examination report. If the report does not include fully detailed descriptions of pathology and all test reports, including adequate responses to the specific opinions requested, the report must be returned for corrective action. 38 C.F.R. § 4.2 (1996). 7. Thereafter, the RO should readjudicate the claims for service connection for Eustachian tube dysfunction with hearing loss, and compensable ratings for service-connected hemorrhoids and service-connected vaginitis, with consideration given to all of the evidence of record. 8. If legally appropriate, the RO should then readjudicate the claim for entitlement to a 10 percent rating under the provisions of 38 C.F.R. § 3.324 for separate noncompensable service-connected disabilities, from October 1, 1992, to April 15, 1994. 9. If any benefit sought on appeal, for which an appeal has been perfected, remains denied, the veteran and his representative should be furnished with a supplemental statement of the case (SSOC) and provided a reasonable opportunity to respond thereto. While this case is in remand status, the veteran and his representative are free to submit additional evidence and argument on the questions at issue. Quarles v. Derwinski, 3 Vet.App. 129, 141 (1992); Booth v. Brown, 8 Vet.App. 109, 112 (1995). Thereafter, subject to current appellate procedures, the case should be returned to the Board for further review, as appropriate. The veteran need take no action until she is so informed. The purpose of this REMAND is to obtain additional evidence. No inference should be drawn regarding the final disposition of the claim as a result of this action. This claim must be afforded expeditious treatment by the RO. The law requires that all claims that are remanded by the Board of Veterans’ Appeals or by the United States Court of Veterans Appeals for additional development or other appropriate action must be handled in an expeditious manner. See The Veterans’ Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 302, 108 Stat. 4645, 4658 (1994), 38 U.S.C.A. § 5101 (West Supp. 1996) (Historical and Statutory Notes). In addition, VBA’s ADJUDICATION PROCEDURE MANUAL, M21-1, Part IV, directs the ROs to provide expeditious handling of all cases that have been remanded by the Board and the Court. See M21-1, Part IV, paras. 8.44-8.45 and 38.02-38.03. L. M. BARNARD Member, Board of Veterans' Appeals 38 U.S.C.A. § 7102 (West Supp. 1996) permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991 & Supp. 1996), a decision of the Board of Veterans' Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans' Judicial Review Act, Pub. L. No. 100-687, § 402, 102 Stat. 4105, 4122 (1988). The date that appears on the face of this decision constitutes the date of mailing and the copy of this decision that you have received is your notice of the action taken on your appeal by the Board of Veterans' Appeals. Appellate rights do not attach to those issues addressed in the remand appended to the Board’s decision, because a 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) (1996). - 2 -