Citation Nr: 0007950 Decision Date: 03/23/00 Archive Date: 03/28/00 DOCKET NO. 95-42 136 ) 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 disability manifested by an enlarged heart. 3. Entitlement to a compensable disability evaluation for a duodenal ulcer. WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD R. Acosta, Counsel INTRODUCTION The veteran served on active duty from April 1989 to July 1995. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 1995 rating decision of the Department of Veterans Affairs (VA) Montgomery, Alabama, Regional Office (RO). They were remanded by the RO in July 1998 and April 1999 for additional development, and are now back at the Board. FINDINGS OF FACT 1. The veteran entered service with no evidence of hypertension, and he had several high blood pressure readings during service, but his blood pressure has been shown to currently be within normal limits. 2. There is no competent evidence in the record demonstrating that the veteran currently suffers from a disability manifested by an enlarged heart. 3. There is no competent evidence in the record demonstrating that the service-connected duodenal ulcer is currently at least mild, with recurring symptoms once or twice a year. CONCLUSIONS OF LAW 1. The claim of entitlement to service connection for hypertension is not well grounded or capable of substantiation. 38 U.S.C.A. § 5107(a) (West 1991). 2. The claim of entitlement to service connection for a disability manifested by an enlarged heart is not well grounded or capable of substantiation. 38 U.S.C.A. § 5107(a) (West 1991). 3. A compensable disability evaluation for the service- connected duodenal ulcer is not warranted. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.114, Part 4, Diagnostic Code 7305 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Initially, the Board notes that entitlement to service connection for a particular disability requires evidence of the existence of a current disability and evidence that the disability resulted from a disease or injury incurred in or aggravated during service. 38 U.S.C.A. § 1110 (West 1991). Service connection may also be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (1999). Every claimant, however, bears the burden of submitting evidence that his or her claim of entitlement to service connection is well-grounded. 38 U.S.C.A. § 5107(a) (West 1991). A well-grounded claim is one which is plausible, i.e., meritorious on its own and capable of substantiation. Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). Unlike civil actions, more than just an allegation is required in order to prevail in a claim for VA benefits. In particular, it is noted that the claimant (who is, generally, a veteran) needs to submit supporting evidence that is sufficient to justify a belief by a fair and impartial individual that the claim for VA benefits is plausible. Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992); Grivois v. Brown, 6 Vet. App. 136, 139 (1994). A claim for service connection benefits is considered to be well grounded when the following three criteria are met: (1) evidence of a current disability, as provided by a medical diagnosis; (2) evidence of incurrence or aggravation of a disease or injury in service, as provided by either lay or medical evidence, as the situation dictates; and (3) a nexus, or link, between the inservice disease or injury and the current disability, as provided by competent medical evidence. See Caluza v. Brown, 7 Vet. App. 498, 506 (1995); 38 C.F.R. § 3.303 (1999). This means that there must be evidence of a disease or injury during service, a current disability, and a link between the two. Further, the evidence must be competent. That is, the presence of a current disability requires a medical diagnosis; and, where the claimant intends to link the current disorder to a cause during service or a service-connected disability, a competent opinion of a medical professional is required. See Caluza at 504; Reiber v. Brown, 7 Vet. App. 513 (1995). Whenever a claimant has not met the burden of submitting evidence sufficient to justify a belief by a fair and impartial individual that a claim for service connection benefits is well-grounded, VA has no duty to assist him or her in the development of facts pertinent to such claim, to include obtaining medical opinions. 38 U.S.C.A. § 5107. Further, if the veteran does not submit a well-grounded claim, the appeal of the claim must fail. 38 U.S.C.A. § 5107(a); Murphy, 1 Vet. App. at 81. Regarding the above, it is noted that the U.S. Court of Appeals for Veterans Claims ("the Court," known as the United States Court of Veterans Appeals prior to March 1, 1999) has said that the governing law, 38 U.S.C.A. § 5107(a), [R]eflects a policy that implausible claims should not consume the limited resources of the VA and force into even greater backlog and delay those claims which - as well grounded - require adjudication. . . . Attentiveness to this threshold issue is, by law, not only for the Board but for the initial adjudicators, for it is their duty to avoid adjudicating the implausible claims at the expense of delaying well grounded ones. Grivois v. Brown, 6 Vet. App. 136, 139 (1994). In Epps v. Gober, 126 F.3d 1464 (Fed. Cir. 1997), cert. denied, 524 U.S. 940 (1998), the United States Court of Appeals for the Federal Circuit (Federal Circuit) held that, under 38 U.S.C. § 5107(a), VA has a duty to assist only those claimants who have established well grounded (i.e., plausible) claims. More recently, the Court issued a decision holding that VA cannot assist a claimant in developing a claim which is not well grounded. Morton v. West, 12 Vet. App. 477 (July 14, 1999), req. for en banc consideration by a judge denied, No. 96-1517 (U.S. Vet. App. July 28, 1999) (per curiam). First Issue Entitlement to service connection for hypertension: In addition to the above cited statutory and regulatory provisions, service connection may also be established for a current disability on the basis of a "presumption" under the law to the effect that certain chronic diseases manifesting themselves to a certain degree within a certain time after service must have had their onset in service. See, 38 U.S.C.A. §§ 1110, 1112, 1131 and 1137 (West 1991); 38 C.F.R. §§ 3.303, 3.304, 3.307 and 3.309(a) (1999). Service connection for hypertension may be established based on a legal presumption if it is shown that the disease manifested itself to a degree of 10 percent or more within one year from the date of the veteran's separation from active military service. See, 38 U.S.C.A. § 1112 (West 1991); 38 C.F.R. §§ 3.307 and 3.309 (1999). In the present case, the veteran contends that he developed hypertension during service and that he is therefore entitled to be service-connected for that disability. A review of the record reveals no evidence of the manifestation of hypertension upon enlistment. In this regard, it is noted that the report of the medical examination for induction that was conducted in March 1989 reveals a normal clinical evaluation of the veteran's heart and vascular system, with a blood pressure reading of 116/80. Also, the veteran denied, in his report of medical history for induction of the same date, ever having had, or currently having, high or low blood pressure. The service medical records, however, show several occasions in which the veteran had blood pressure checks that were apparently ordered due to high blood pressure readings. In this regard, it is noted that, in November 1991, five blood pressure readings were recorded over a five-day period, with 149/89 being the highest reading. In June 1992, the veteran was informed that another series of blood pressure readings was suggested because "[y]our blood pressure is elevated," and, this time, 152/84 was the highest reading obtained in the series. Also in June 1992, the veteran was seen in consultation with complaints of chest pains, and the assessment was listed as chest wall pain, rule out hypertension. In January 1994, the veteran indicated, in a report of medical history, that he had had, or currently had, high or low blood pressure, and another five-day blood pressure check was recorded, in the report of medical examination of the same date, with 139/78 among the highest blood pressure readings recorded. Finally, in his February 1995 report of medical history for separation purposes, the veteran again indicated that he had had, or currently had, high or low blood pressure, although he also wrote in that report that "I have never been treated for high blood pressure," and the Board notes that his heart and vascular system were clinically evaluated as normal in the report of medical examination of the same date, in which a blood pressure reading of 132/60 was reported. At a January 1996 RO hearing, the veteran indicated that "[t]he hypertension ... they say it don't [sic] exist. I guess it deals with my exercises, because it never goes up." The report of an August 1997 VA spine medical examination reveals a blood pressure reading of 140/78, while the report of a February 1998 VA general medical examination reveals complaints of the blood pressure historically being "up and down," but currently being "down," and blood pressure readings of 136/94, 146/104 and 144/88. "History of hypertension, on diet," was listed as the pertinent diagnosis and, since it remained unclear whether a diagnosis of hypertension was indeed warranted in this case and, if it was, whether the onset had been during or after service, the Board remanded this matter in April 1999 to have the veteran re-examined and obtain from the examiner a medical opinion. The examination was conducted in September 1999, and the report is of record. According to the report of the above VA "hypertension" examination, the veteran indicated that he was told within the years of 1990 and 1995 that he had borderline blood pressure. He also said that he had three to five-day blood pressure checks during that time, but that the pressure "never got extremely high," that he was nevertheless advised on diet, losing weight and exercise, and that he even took medication for high blood pressure once during service. Upon a review of the entire file, the examiner noted that there were in fact three to four-day blood pressure checks on three different occasions during service, with diastolic pressure readings ranging between 60 and 89, and systolic pressure readings ranging between 124 and 152. The subscriber of the above report also noted that, in January 1993, the veteran had a motor vehicle accident and his blood pressure was slightly elevated at 146/96, which the examiner noted "was probably temporary elevation secondary to injury and the pain associated with the injury." He further noted that, in August 1997, the blood pressure was 140/78, and that, in February 1998, blood pressure readings revealed readings of systolic pressure ranging between 136 and 146, with diastolic readings ranging between 94 and 104, "which indicated mild diastolic blood pressure elevation." It was noted that the veteran said that he was on his own diet for his history of hypertension, and that he gave a history of some headaches at times, which stayed for days at times. He also said that he did not know whether the headaches were related to stress, and denied taking any kind of antihypertensive medications at the time of the examination. According to the above report, the veteran denied smoking cigarettes, said that he used alcoholic drinks only occasionally, and reported that he had been monitoring his blood pressure, which he checked when he went to the store at least once a month, and which he said was currently "all right." On examination, the veteran was noted to be in no distress at the time, and to have the following blood pressure readings: 152/69 sitting (with pulse of 75), 138/72 lying (with pulse of 64), and 152/84 standing (with pulse of 78), all at 10 in the morning; and 139/66 sitting (with pulse of 72), 152/68 lying (with pulse of 75), and 149/84 standing (with pulse of 87), all at 11:50 in the morning. The head was "normocephalic," there was no increased jugular venous distention, nor carotid bruits, and the heart revealed normal S1 and S2, regular rhythm, and no murmurs. Peripheral pulses were bilaterally symmetrical, there was no peripheral edema, cyanosis or clubbing, lungs were clear with normal breath sounds, no adventitious sounds were heard, and there was no organomegaly. Diagnostic and clinical tests were all normal, and a chest X-Ray revealed clear lungs, with a normal "cardiomediastinal" silhouette and no cardiomegaly, nor masses. No pneumothorax was noted, no significant bony abnormalities were evident, and the impression was of a normal chest. The diagnosis was listed as history of hypertension, and the examiner added the following medical opinion: From the claim[s] folder review, it is noted that this veteran has had intermittent borderline elevation of systolic blood pressure as well as mild elevation of diastolic blood pressure since 1991. The systolic blood pressure readings have ranged from 132 to 152, and the diastolic blood pressure readings have ranged from 60 to 100. On many occasions, he is noted to have had normal blood pressure readings. In addition, it is noted that this patient has a lower back problem. Periodic exacerbations of pain may cause elevation in the blood pressure. This veteran's onset of intermittent, mild hypertension has been noted since 1991 onwards, although not so much up until the February of 1998 examination, which indicated more elevated diastolic blood pressure readings. On the current examination, his diastolic blood pressure readings were noted to be within normal limits, and he is noted to have borderline elevation of systolic blood pressure. This veteran's intermittent hypertension needs to be monitored more closely, but the does not need any medication at this time. As indicated earlier in this decision, every claimant has the initial burden of submitting a claim for service connection that is well grounded or capable of substantiation, i.e., a claim that meets all three Caluza criteria. In the present case, the Board finds that, even though there were several high blood pressure readings noted during service, the Caluza criterion of a present disability has not been met, as the veteran has been said to currently have "intermittent," rather than chronic, hypertension, and, more importantly, his blood pressure has been noted to currently be "within normal limits," with no current need for medication. Insofar as at least one of the Caluza criteria has not been met, the Board concludes that the claim for service connection for hypertension is not well grounded or capable of substantiation. Additionally, the Board notes that the veteran has not reported that any competent evidence exists that, if obtained, would establish a well-grounded claim for service connection for hypertension. Under these circumstances, VA has no further duty to assist the veteran in developing the matter on appeal. Epps v. Brown, 9 Vet. App. 341 (1996); Robinette v. Brown, 8 Vet. App. 69 (1995). Should such evidence be obtained at any time in the future, the veteran hereby is encouraged to submit such evidence in an effort to reopen his claim. Second Issue Entitlement to service connection for a disability manifested by an enlarged heart: The veteran contends that he developed an enlarged heart during service and that he believes that he is therefore entitled to be service-connected for that disability. At the outset, the Board notes that the veteran is already service- connected for non-cardiac chest pains. A review of the record reveals no competent evidence of an enlarged heart at any time during service, to include at the time of separation, and the Board notes that chest radiographs obtained in January 1994 and March 1995 were both negative. There were several instances in which the veteran complained of chest pain during service. (See, for instance, service medical records dated in November 1989, September 1990, June 1992 and September 1993.) However, as noted above, the veteran is already service-connected for non- cardiac chest pains. At the January 1996 RO hearing, the veteran said that he was told by a physician during service that he had an enlarged heart, which "I guess they said it is an athletic heart." He denied taking any medicine for his enlarged heart and, when asked how did he consider an enlarged heart to be a disability, the veteran answered "[b]ecause of the chest pain," for which, again, the Board notes that he is already service-connected. According to the report of the February 1998 VA general medical examination, the veteran said that he was told in the military that his heart was larger than normal. On examination, however, it was noted that the heart revealed S1 and S2, with irregular rhythm, but no heart murmurs noted. An electrocardiogram reportedly revealed normal sinus rhythm and minimal voltage criteria for left ventricular hypertrophy. Therefore, the examiner said that it was a "borderline electrocardiogram," although he rendered no pertinent diagnosis. In its remand of April 1999, the Board instructed the RO to have the veteran re-examined by a VA physician, in order to attempt to answer the questions of whether the veteran has an enlarged heart, as he claims, and whether such finding represents a heart disability. The examination was conducted in September 1999, and its report is of record. According to the report of the September 1999 VA "heart" medical examination, the veteran reported that he had been told that he had an enlarged heart for the past nine years. He said that it was called an "athlete's heart," and that his father also had had an enlarged heart, which the veteran referred to as a "bad heart." The veteran's father had suffered from high blood pressure and diabetes and died at the age of 78 years, on the day prior to this examination, while the mother of the veteran reportedly died of a heart attack at the age of 66 years. The above report also reveals that the veteran gave a history of chest pains, which he said were usually noted in the left pectoral area, like a cramp, lasted for a couple of seconds, up to 30 seconds, and was "usually relieved." This was not an exertional pain, nor was it associated with nausea, vomiting or sweating. The veteran denied any history of dyspnea, shortness or breath with exertion, fatigue, dizziness and syncopal spells. He said that he had never been treated for any heart problems, and denied a history of coronary artery disease, or a history of any rheumatic heart disease during childhood. He further said that he was able to walk for a couple of miles at a normal pace, but that if he had to do "speedwalking," he could probably walk around one-fourth of a mile, with his legs becoming tired, as he was "an out of shape person and I don't have the wind to do it." He said that he was able to climb one flight of stairs without any shortness of breath, denied any paroxysmal nocturnal dyspnea, and said that he had never had a stress test in the past. He reported that electrocardiograms had been normal in the past. The subscriber of the above report also indicated that a December 1993 electrocardiogram report in the file revealed a normal sinus rhythm and was within normal limits, and that the report of a VA medical examination conducted more recently, in February 1998, showed that the minimal criteria for left ventricular hypertrophy were met, with a "borderline EKG." Currently, an EKG revealed, according to the examiner, a normal sinus rhythm with a ventricular rate of 61 beats per minute, and a nonspecific intraventricular block, and a chest X-Ray revealed no evidence of any cardiomegaly or masses. Regarding the physical examination, the subscribing physician referred the reader to the above discussed report of a September 1999 VA "hypertension" medical examination, adding this time that the veteran was in no distress and had no carotid bruits, nor jugular venous distention. His heart revealed a normal sinus rhythm, with no murmurs. Peripheral pulses were bilaterally symmetrical, with no cyanosis or clubbing noted, lungs revealed normal breath sounds, and no adventitious sounds were heard. In the diagnosis section, the examiner again referred the reader to the above discussed report of a September 1999 VA "hypertension" medical examination, and added his opinion to the effect that "[t]here is no evidence of any enlargement of the heart at the present time." The Board finds that none of the Caluza criteria have been met in the present case, as there is no competent evidence in the record of a disability manifested by an enlarged heart at any time. Insofar as none of the Caluza criteria has been met, the Board concludes that the claim for service connection for a disability manifested by an enlarged heart is not well grounded or capable of substantiation. Additionally, the Board notes that the veteran has not reported that any competent evidence exists that, if obtained, would establish a well-grounded claim for service connection for a disability manifested by an enlarged heart. Under these circumstances, VA has no further duty to assist the veteran in developing the matter on appeal. Epps v. Brown, 9 Vet. App. 341 (1996); Robinette v. Brown, 8 Vet. App. 69 (1995). Again, however, the Board notes that, should such evidence be obtained at any time in the future, the veteran is encouraged to submit such evidence in an effort to reopen his claim. Third Issue Entitlement to a compensable disability evaluation for a duodenal ulcer: Initially, the Board finds that, in accordance with 38 U.S.C.A. § 5107(a) (West 1991), and Murphy v. Derwinski, 1 Vet. App. 78 (1990), the veteran has presented a well- grounded claim for an increased rating. The facts relevant to this appeal have been properly developed and VA's obligation to assist the veteran in the development of his claim (not to be construed, however, as shifting from the claimant to VA the responsibility to produce necessary evidence, per 38 C.F.R. § 3.159(a) (1999)), has been satisfied. Id. Disability evaluations are based upon the average impairment of earning capacity as determined by VA's Schedule for Rating Disabilities. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. § 4.1, Part 4 (1999) (Schedule). Separate rating codes identify the various disabilities. In determining the current level of impairment, the disability must be considered in the context of the whole recorded history. 38 C.F.R. § 4.2 (1999). An evaluation of the level of disability present also includes consideration of the functional impairment of the veteran's ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10 (1999). 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 (1999). A review of the record reveals that the service-connected gastrointestinal disability is rated as noncompensable, in accordance with § 4.31, which the Board notes mandates the assignment of such a rating when the Schedule does not provide a zero percent evaluation and the requirements for a compensable evaluation are not met, and under the provisions of Diagnostic Code 7305 of the Schedule, which addresses the rating of duodenal ulcers. See, 38 C.F.R. § 4.114, Part 4, Diagnostic Code 7305 (1999). A rating of 10 percent is warranted when a service-connected duodenal ulcer is mild, with recurring symptoms once or twice a year, while a 20 percent rating is warranted when a service-connected duodenal ulcer is moderate, with recurring episodes of severe symptoms two or three times a year averaging 10 days in duration, or with continuous moderate manifestations. See, 38 C.F.R. § 4.114, Part 4, Diagnostic Code 7305 (1999). Diagnostic Code 7305 also provides for a rating of 40 percent when the disability is shown to be moderately severe, with symptoms less than those for a severe rating, 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. This diagnostic code also provides for a maximum rating of 60 percent when it is shown that the disability is severe in nature, with the pain only partially relieved by standard ulcer therapy, and with periodic vomiting, recurrent hematemesis or melena, and manifestations of anemia and weight loss productive of definite impairment of health. See, 38 C.F.R. § 4.114, Part 4, Diagnostic Code 7305 (1999). At the January 1996 RO hearing, when asked what problems was he having with his duodenal ulcer, the veteran responded "[j]ust eating ... if I eat a certain food, it just comes back up, or it gives me diarrhea." He acknowledged that he had not lost any weight, and said that he tried to eat three meals a day, that he took no medication for this disability and that he did not know whether he had a bleeding ulcer or not. The report of the February 1998 VA general medical examination reveals a history of a diagnosis of a stomach ulcer in 1989, with current trouble digesting "certain foods," especially at night-time, involving occasional vomiting, and a recent occasion in which, after vomiting, the veteran noticed slight blood when clearing his throat. The veteran denied using antacids. He also denied a history of abdominal pains, melena or hematemesis. On examination, the veteran was noted to be slightly obese, but soft and with no tenderness noted in the epigastric region. There was no tenderness noted in the abdomen, either, and bowel sounds were normal. Diagnostic and clinical test results, which included urinalysis, a complete blood count and uric acid test, were all normal, other than the blood count being slightly elevated. The pertinent diagnosis was listed as "[p]ast history of peptic ulcer disease, upper gastrointestinal series could not be scheduled since the veteran reportedly is going to be out of the state for the next several months." According to the report of a September 1999 VA "stomach, duodenum and peritoneal adhesions" medical examination, the veteran said that he was diagnosed with duodenal ulcer in 1989, at which time he was treated with Tagamet. A review of the file by the examiner revealed that the veteran was noted to have a duodenal bulb ulcer in June 1989, and that, as of August 1989, it was noted that the duodenal ulcer was no longer seen, with the rest of the examination being normal. It was noted that the veteran gave a history of vomiting sometimes after eating, and reported that he occasionally used over-the-counter Tagamet for increased gas. Otherwise, he did not take any prescription medications. He had no history of any hematemesis or melena, nor a history of any circulatory disturbance after meals. He gave a history of some diarrhea at times, depending on what he ate, and reported that, if he ate "very greasy food," such as Kentucky Fried Chicken, he noticed some diarrhea. Otherwise, no history of any gastrointestinal disturbances, constipation, colicky pains or abdominal distention was reported. Also, there was no history of any weight gain or weight loss, and the veteran reported that he had always weighed between 215 and 220 pounds since his discharge from the military, currently reporting his bodyweight as between 220 and 230 pounds. Regarding the physical examination of the veteran and the results of diagnostic and clinical tests, the above report refers the reader to the reports of the hypertension and heart examinations of the same date, which were discussed earlier in this decision. The subscribing examiner, however, indicated that there were no signs of anemia, that the abdomen was soft and nontender, with no organomegaly, and that there were normal bowel sounds. It was also noted that an upper gastrointestinal examination revealed the esophagus to be "distensible," with no evidence of hiatal hernia or reflux. The stomach, duodenum and visualized small bowel appeared normal, and there was no evidence of ulceration, neoplasm or obstruction. The impression was listed as a normal upper gastrointestinal examination, and the diagnosis was listed as past history of duodenal ulcer with no evidence of ulceration, neoplasm or obstruction on the current upper gastrointestinal study and other examination findings as described. As shown above, the competent evidence in the record does not reveal that the service-connected duodenal ulcer currently is at least mild, with recurring symptoms once or twice a year. The veteran was diagnosed with a duodenal ulcer during service but, currently, there is no evidence of recurrence or reactivation of said disability, and the veteran has acknowledged that he only has occasional problems involving vomiting and some diarrhea when he eats "certain" (essentially, "very greasy") foods, which the Board notes is certainly to be expected even from an individual with no prior history of any gastrointestinal difficulties. Insofar as the schedular criteria for at least a 10 percent disability evaluation for this disability have not been met, the Board concludes that an increased rating for the service- connected duodenal ulcer is not warranted. Finally, the Board notes that the record appears to show that the RO has not considered the question of a referral of the above matter to the Chief Benefits Director or the Director, Compensation and Pension Service, for the assignment of an extra-schedular rating under 38 C.F.R. § 3.321(b)(1) (1999). This regulation provides that, to accord justice in an exceptional case where the schedular 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 extra- schedular evaluation commensurate with the average earning capacity impairment. The governing criteria for such an award is a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. The Court has held that, while the Board is precluded by regulation from assigning an extra-schedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance, 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). Regarding the above, the Board also notes that the Court has further held that the Board must address referral under 38 C.F.R. § 3.321(b)(1) only where circumstances are presented which the Director of VA's Compensation and Pension Service might consider exceptional or unusual. Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Having reviewed the evidentiary record with these mandates in mind, the Board is of the opinion that a referral for extra-schedular consideration is not warranted in the present case, due to the lack of a reasonable basis for further action on this question. See, VAOPGCPREC. 6-96 (1996). CONTINUED ON THE NEXT PAGE ORDER 1. Service connection for hypertension is denied. 2. Service connection for a disability manifested by an enlarged heart is denied. 3. A compensable disability evaluation for the service- connected duodenal ulcer is denied. JEFF MARTIN Member, Board of Veterans' Appeals