Citation Nr: 0006367 Decision Date: 03/09/00 Archive Date: 03/17/00 DOCKET NO. 95-24 187A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Entitlement to service connection for a cardiovascular disorder including hypertension. 2. Entitlement to service connection for a sinus disorder. 3. Entitlement to service connection for a gastrointestinal disorder. 4. Entitlement to service connection for a kidney disorder. 5. Entitlement to service connection for bilateral hearing loss. 6. Entitlement to service connection for tinnitus. 7. Entitlement to a compensable rating for a skin disorder. 8. Entitlement to a compensable rating for hemorrhoids. WITNESS AT HEARING ON APPEAL Appellant INTRODUCTION The veteran had active service from May 1972 to December 1992. This matter comes before the Board of Veterans' Appeals (Board) on appeal from decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. As noted below, the Board finds that additional development is necessary in regard to the issue of entitlement to service connection for a gastrointestinal disorder. Accordingly, that issue is addressed in the REMAND section hereinafter. FINDINGS OF FACT 1. Hearing loss for VA purposes was not shown in service or to a compensable degree within one year after service; there is no competent medical evidence linking the veteran's current hearing impairment to disease or injury in service. 2. There is no competent medical evidence linking any current cardiovascular disorder (including hypertension), sinus disorder, kidney disorder, or tinnitus to disease or injury in service. 3. The veteran's skin disorder is manifested by complaints of an occasional rash with itching, but it does not involve an exposed surface or extensive area nor does it result in constant exudation or itching, extensive lesions, or marked disfigurement. 4. The veteran's hemorrhoids are recurrent, but are no more than mild or moderate; they are not large or thrombotic, irreducible, with excessive redundant tissue. CONCLUSIONS OF LAW 1. The claims of entitlement to service connection for bilateral hearing loss, cardiovascular disorder (including hypertension), sinus disorder, kidney disorder, and tinnitus are not well grounded. 38 U.S.C.A. § 5107 (West 1991). 2. A compensable disability evaluation for a skin disorder is not warranted. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.1, 4.7, 4.20, 4.118, Diagnostic Codes 7899- 7806 (1999). 3. A compensable disability evaluation for hemorrhoids is not warranted. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.114, Diagnostic Code 7336 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Factual Background The veteran's service medical records show that he was seen in January 1976 with complaints of stomach cramps, dizziness, and sinus drainage. The impression was sinusitis with flu or cold. In May 1982, he was seen for complaints of a sore throat and runny nose of three weeks duration. The assessment was acute pharyngitis. In June 1985, he reported having yearly problems with eyes itching, runny nose, and sneezing. The assessment was allergic rhinitis. In November 1986, he had complaints of cough and sinus infection. X-ray examination of the sinuses showed a questionable air-fluid level in the right maxillary. The assessment included sinusitis. In January 1987, he was seen for follow-up on questionable sinus infection. The assessment was sinusitis. In June 1987, he was seen for complaints of chest pains for the previous three weeks. It was also noted that he reported the pain started that day when lifting a desk. It was further noted that he had a history of reflux pain that was different from this pain. An electrocardiogram was noted to be within normal limits. The assessment was possible angina. The report of an internal medicine consultation, also performed in June 1987, noted the veteran's chest was symmetrical, clear to auscultation and percussion. There was no murmur, gallop, or premature beats. The examiner stated that he felt this was probably a non-cardiac type of chest pain, possible pulled muscle, etc. However, it was noted that the veteran should have a treadmill test and have serum cholesterol and triglyceride checked. In August 1987, an echocardiogram was within normal limits and an exercise stress test showed a fair exercise capacity, but noted rare ventricular premature contractions. In October 1988, he underwent a vasectomy and was noted to have mild renal insufficiency. A September 1990 audiometry report notes that the veteran had a hearing loss profile of H1 and that he was routinely exposed to hazardous noise. Puretone thresholds in the left ear were 0 decibels at 500 and 1000 Hertz, 5 decibels at 2000 Hertz, 15 decibels at 3000 Hertz, and 20 decibels at 4000 Hertz. Puretone thresholds in the right ear were 10 decibels at 500 Hertz, 0 decibels at 1000 and 2000 Hertz, 5 decibels at 3000 Hertz, and 15 decibels at 4000 Hertz. A service medical record dated in November 1990 notes that the veteran had a sudden onset of post-exertional chest pains. It was reported that he had a history of exertional angina of two years duration, with electrocardiogram, treadmill, and echocardiogram all negative. He was hospitalized to rule out myocardial infarction. Discharge diagnoses included chest pain and asymptomatic ventricular premature beats. An echocardiogram, performed in January 1991, was normal. In May 1991, he was seen with complaints of several hours of substernal chest pain. The assessment was gastroesophageal reflux. He was hospitalized in March 1992 for complaints of chest pains. Cardiovascular examination showed regular rate and rhythm, with no murmur, rub or gallop appreciated. Electrocardiogram revealed normal sinus rhythm and left axis deviation. It was indicated that no acute changes were noted and there was no change from the electrocardiogram of November 1991. He underwent a cardiovascular stress test using a treadmill. The discharge diagnosis was atypical chest pain, myocardia infarction ruled out, presumed secondary to gastroesophageal reflux. Later in March 1992, it was noted that he continued to experience atypical chest pain. He reported being hospitalized to rule out myocardia infarction and that they said it was gas, but he did not think so. It was noted that his pain occurred at rest and with exertion, and it was located mid sternum. The use of Zantac had not improved his gastrointestinal discomfort. The assessment was hyperlipoproteinemia with increased high-density lipoprotein minimizing risk of total cholesterol. In June 1992, he was seen for a rash on the center of his chest for 30 days. He reported that the rash had occurred several times in the past and that medication made it disappear for a short time. He also reported that there was an itching sensation on occasions. The assessment was rash, type unknown. In September 1992, he was again seen for treatment of a rash on the center of his chest for 3 1/2 months. Observation noted a rash that was 1/4 inch in diameter with several small spots around it. It was brownish in appearance. The assessment was rash in center of chest. The veteran's retirement physical examination report dated in October 1992 shows that he reported a history of various problems including: ear, nose, and throat trouble; chronic or frequent colds; hay fever; skin disease; shortness of breath; pain or pressure in the chest; palpitation or pounding heart; and heart trouble. The physician noted on the report of medical history form that the veteran stated he had mucous in the throat and his nose ran year round, seasonal hay fever, chest pain with rapid beating heart and that he was hospitalized three times and had had a cardiac work-up all three times and cleared. He coughed up phlegm at night and had frequent indigestion. Physical examination found his nose and sinuses, heart and vascular system, and genitourinary system were all normal. Audiometric testing revealed puretone thresholds in the left ear of 0 decibels at 500 and 1000 Hertz, 5 decibels at 2000 Hertz, 15 decibels at 3000 Hertz and 0 decibels at 4000 Hertz. Puretone thresholds in the right ear were 10 decibels at 500 Hertz, 0 decibels at 1000 Hertz, 10 decibels at 2000 and 3000 Hertz, and 35 decibels at 4000 Hertz. A consultation report, dated in November 1992, shows that the veteran had undergone Holter monitor testing that found two to three second pauses without symptoms. The assessment was asymptomatic sinus pauses with no indication for SSS or for need for pacemaker. A VA audiology examination report dated in February 1993 notes that the veteran had complaints of decreased hearing in his left ear greater than his right for approximately the past five to six years. He stated that he had some mild problems understanding people, primarily in crowds, but he had no of complaints of tinnitus. Audiometric testing revealed puretone thresholds in the right ear of 0 decibels at 500 and 1000 Hertz, 5 decibels at 2000 Hertz, 0 decibels at 3000 Hertz, and a 20 decibel loss at 4000 Hertz. The left ear had puretone thresholds of 0 decibel loss at 500 and 1000 Hertz and a 5 decibel loss at 2000, 3000, and 4000 Hertz. The pure tone threshold average was six in the right ear and four in the left ear, with speech discrimination scores of 92 percent bilaterally. The report of a general medical examination dated in February 1993 notes that the veteran reported a history of several episodes of chest pain, at rest and on exertion, that began in the late 1980s. It was noted that he had been hospitalized twice for evaluation of his chest pains and that they had been considered non-cardiac in nature. It was also reported that, on one hospitalization, he was noted to have elevated blood pressure, but that he presently took no medication for blood pressure. Examination revealed that his blood pressure was 138/90 while sitting, 142/92 while recumbent, and 138/90 while standing. Examination of the cardiovascular, respiratory, and digestive systems were noted to be within normal limits. Final diagnoses included fungal infection of the chest; history of hypertension, normotensive at the present time; atypical chest pain by history; hemorrhoids in the six and 12 o'clock position; and a history suggestive of hiatal hernia. A VA cardiac examination report dated in February 1993 shows that the veteran had a history of chest pain since the late 1980's previously evaluated by stress tests and Holters and echocardiograms, all of which were normal. His blood pressure was 140/90. A VA arteriovenous examination report dated in February 1993 notes that the veteran's blood pressure was 140/92 and his pulsations were normal. There was no evidence of cardiac involvement. The final diagnosis was that there was no evidence of disease of the arteries and veins. A VA examination report for hypertension dated in February 1993 shows that blood pressure readings varied from 138/90 to 142/92, and that the veteran currently was taking no medication. The diagnosis was normotensive individual. The report of a VA examination of the rectum and anus dated in February 1993 notes that the veteran reported bleeding during flare-ups, but no soiling, incontinence, tenesmus, dehydration or malnutrition. He had had about two episodes of flare-ups in the last four years. Rectal examination showed that he had two enlarged hemorrhoids at the six and 12 o'clock positions. The diagnosis was hemorrhoid flare-up. A VA dermatology examination report dated in February 1993 shows that the veteran had hyperpigmented areas measuring about one inch across, and he had about three of them in the chest region. There was some scaliness to the lesion and central clearing, but no nervous manifestation. The diagnosis was fungal infection of the chest wall. VA outpatient treatment records from 1993 to 1998 show that the veteran was seen in May 1993 with complaints that his eyes were red and puffy with extreme itching. It was noted that on the day of the examination there was mild itching and redness. It was further indicated that he had a past medical history that included positive sinus. In June 1993, he was seen in the genitourinary clinic when it was noted that he had a long history of urinary frequency. The impression was urinary frequency, etiology unknown. In November 1993, he was seen by a dermatology resident and it was reported that he had had hyperpigmented papules and patches on the center chest and right wrist since about 1991. Examination found a reticulate hyperpigmentated patch with slight scale center on the anterior chest and hyperpigmented linear plaque on the right elbow. The impression was atypical tinea versicolor versus seborrhea lichen planus, less likely (it was noted that the veteran used men's cologne and could have berloque dermatitis) and alopecia areata. An October 1998 treatment record from the dermatology clinic noted that the veteran reported that the rash on his chest would come and go several times a year. Examination revealed fine scaling patch over the sternum fairly well circumscribed with no lesions noted on shoulders or inframammary folds. The assessment was tinea versicolor versus seborrheic dermatitis. At a personal hearing before a hearing office at the RO in September 1995, the veteran testified that he first noticed his skin disorder upon his return from the Persian Gulf. He said that it was a small dot that would scab over. If he wiped the scab off, then it would bleed. He went to the clinic and was given cream that made it go away, but it continued to come back. He reported that he continued to receive treatment for the skin condition about every four to six months. The rash had continued to grow on his chest to about three to four inches in diameter and it itched. He also testified that his hemorrhoids were first treated in 1986 or 1987. His hemorrhoids were all external and were going to be operated on, but they got better. Since that time, he had had occasional bleeding and had to change his underwear three to four times per day. He still had blood from time to time. He reported that he had never had surgery for the hemorrhoids. The veteran also testified concerning the various conditions for which he was seeking service connection. He testified that he was hospitalized several times in service and told that it was for a heart condition. He reported that his blood pressure had been elevated and he had experienced chest pains. He was told his heart tried to beat an extra beat, but was basically normal, and that a lot of people had erratic rhythm. At the time of his retirement physical examination, the veteran had to see the internal medicine doctor personally. He wore a Holter monitor for 24 hours, and he was told that his heart paused and that at some point he would need a pacemaker. He stated that he had had no tests for his heart since his retirement. He also testified that he was not on any medication for hypertension. He reported that he developed a serious sinus problem during service. He testified that, when he had a vasectomy during service, the doctor told him that tests indicated that he had a kidney problem. He reported that he had not had any tests performed on his kidneys since service and that he had no specific pain associated with it. Finally, the veteran testified that he first noticed a decrease in his hearing during service and that he could not hear pronunciation. The veteran stated that he worked around turbine engines during his entire military career. He testified that he sometimes had ringing in his ears, which he attributed to being around engine noise in service. The report of a VA examination of the rectum and anus in August 1998 shows that the veteran reported having a history of bleeding in the stool, which he noted after hard bowel movements approximately six to eight times a year. He also noted some soilage of his underclothes. There was no incontinence, although he stated that lately he had noted a little urine spillage at the same time. Physical examination showed a hemorrhoidal tag at 12 o'clock. There was no evidence of veins in the anal canal. There were no fissures and no evidence of bleeding. The diagnoses were moderately severe hemorrhoids, occasionally symptomatic, history of rectal polyps, and elevated uric acid. A VA dermatology examination report dated in August 1998 notes that the veteran had a cobble-stone appearing dry area on the sternum. There was nothing on either shoulder or his back. It was reported that the dry, slightly pigmented irregular area 10 centimeters long and eight centimeters wide, irregular mass on the sternum, was not itching at the time of examination. The veteran stated that cream and shampoo that had been prescribed previously cleared the rash temporarily. At the present time, findings were minimal. The diagnosis was mild dermatitis on the sternum, probably seborrheic dermatitis. It was noted that, during an acute flare-up, a more accurate diagnosis of perhaps pityriasis rosacea could be entertained. There was no treatment indicated at the time and the veteran was advised to continue follow-up. Analysis I. Service Connection Issues The veteran is seeking service connection for a cardiovascular disorder including hypertension, a sinus disorder, a kidney disorder, bilateral hearing loss, and tinnitus. Initially, it must be determined whether the veteran has presented evidence of well-grounded claims; that is, claims that are plausible. If he has not presented well- grounded claims, his appeal must fail with respect to those claims and there is no duty to assist him further in the development of the claims. 38 U.S.C.A. § 5107(a). As explained below, the Board finds that these claims are not well grounded. The law provides that service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131 (West 1991); 38 C.F.R. § 3.303 (1998). However, "[a] determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or disease incurred in service." Watson v. Brown, 4 Vet. App. 309, 314 (1993). Three discrete types of evidence must be present in order for a veteran's claim for VA benefits to be well grounded: (1) There must be competent evidence of a current disability, usually shown by medical diagnosis; (2) There must be evidence of incurrence or aggravation of a disease or injury in service, which may be shown by lay or medical evidence; and (3) There must be competent evidence of a nexus between the inservice injury or disease and the current disability. Such a nexus must be shown by medical evidence. See Epps v. Gober, 126 F.3d 1464, 1468 (Fed. Cir. 1997), cert. denied sub nom. Epps v. West, 118 S. Ct. 2348 (1998); Caluza v. Brown, 7 Vet. App. 498, 506 (1995). A. Service Connection for Bilateral Hearing Loss The veteran contends that he was exposed to loud noises during service and that his current hearing impairment is related to service. The records show that he was periodically examined for hearing impairment during service and that he was routinely exposed to hazardous noise. Service connection may be established for a disability resulting from personal injury suffered or disease contracted in the line of duty or for aggravation of a preexisting injury suffered or disease contracted in the line of duty. 38 U.S.C.A. § 1110 (West 1991). Regulations also provide that service connection may 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). Where a veteran served continuously for 90 days or more during a period of war or during peacetime service after December 31, 1946, and an organic disease of the nervous system, which includes sensorineural hearing loss, becomes manifest to a degree of 10 percent or more within a year from the date of termination of service, such disease shall be presumed to have been incurred in service even though there is no evidence of the disease during the period of service. However, this presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309 (1999). Additionally, for VA purposes, impaired hearing will be considered a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000 and 4000 Hertz is 40 decibels or greater, or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000 and 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385 (1999). The veteran's service medical records indicate that he was routinely exposed to hazardous noise. However, he was periodically examined for hearing impairment during service and no hearing loss disability for VA purposes was shown during service. As noted in the facts reported above, the service medical records show some hearing impairment during service. However, none of the service medical records demonstrate a hearing loss disability under the criteria provided in 38 C.F.R. § 3.385. The VA examination in February 1993, within one year of the veteran's separation from service, shows that none of the auditory thresholds in the frequencies of 500, 1000, 2000, 3000, and 4000 Hertz, were 40 decibels or greater. In addition, the February 1993 examination did not show auditory thresholds in at least three of these frequencies of 26 decibels or greater. However, speech recognition scores using the Maryland CNC word list were 92 percent in each ear. Although this is evidence of some hearing impairment within one year of service, it is not to a compensable degree and presumptive service connection is not applicable to support service connection for bilateral hearing loss. Due to the fact that some hearing impairment was demonstrated shortly after service, the Board requested a VA medical expert opinion as to whether the hearing acuity noted at the February 1993 VA examination represented a hearing loss related to service. In an opinion dated in October 1999, a VA Interim Chief of Audiology/Speech Pathology Service reviewed the pertinent medical evidence and rendered an opinion. He noted that audiologic evaluations in January 1981, June 1984, November 1984, and August 1990 indicate normal hearing thresholds bilaterally. He further noted that the audiologic assessment of February 1993 revealed that the veteran had normal hearing thresholds bilaterally and that an ear disease examination in March 1993 revealed an essentially normal otological examination. According to this specialist, no hearing loss was indicated in the findings of the audiologic evaluation performed in February 1993. This opinion provides no medical nexus between any hearing impairment shown shortly after service and disease or injury in service. The evidence of record does not contain a medical nexus between any current hearing impairment and the veteran's period of service. Accordingly, the claim for service connection for bilateral hearing loss disability is not well grounded. B. Service Connection for Cardiovascular Disorder (including Hypertension), Sinus Disorder, Kidney Disorder and Tinnitus The veteran contends that service connection should be granted for a cardiovascular disorder including hypertension, a sinus disorder, a kidney disorder, and tinnitus. The record shows that the veteran was treated during service for complaints of problems involving his heart, sinuses, and kidneys. However, the record demonstrates that no such chronic disabilities were found in service or on separation from service. Moreover, on numerous VA treatment records and examination reports after the veteran's separation from service, there was no showing that the veteran had any chronic disabilities involving the problems in question. In regard to a heart disorder and hypertension, the February 1993 VA general medical examination showed a history of hypertension but that the veteran was normotensive at that time. It was also noted that the veteran had atypical chest pain by history, but a diagnosis of current chest pain was not noted. No chronic sinus or kidney disorder was shown at the VA examinations in February 1993 or in any other medical evidence. In regard to tinnitus, at the February 1993 VA audiology examination, it was noted that no tinnitus was reported. There is no current medical diagnosis of tinnitus. In short, no medical or other competent evidence showing that the veteran currently has a cardiovascular disorder including hypertension, a sinus disorder, a kidney disorder, or tinnitus has been presented. Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992). The only evidence supporting the veteran's claims for service connection for a cardiovascular disorder including hypertension, a sinus disorder, a kidney disorder, and tinnitus are his own unsubstantiated contentions. While the veteran is certainly capable of providing evidence of symptomatology, "the capability of a witness to offer such evidence is different from the capability of a witness to offer evidence that requires medical knowledge..." Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). Causative factors of a disease amount to a medical question; only a physician's opinion would be competent evidence. Gowen v. Derwinski, 3 Vet. App. 286, 288 (1992). A well-grounded claim requires more than a mere assertion; the claimant must submit supporting evidence. Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992). Since the veteran has submitted no medical or other competent evidence to show that he currently has a cardiovascular disorder including hypertension, a sinus disorder, a kidney disorder, and tinnitus, the Board finds that he has not met the initial burden of submitting evidence sufficient to justify a belief by a fair and impartial individual that these claims are well grounded. 38 U.S.C.A. § 5107. Since the claims are not well grounded, they must be denied. See Edenfield v. Brown, 8 Vet. App. 384, 390 (1995). Finally, as the foregoing explains the need for competent evidence of a current disability which is linked by competent evidence to service, the Board views its discussion above sufficient to inform the veteran of the elements necessary to complete his application for service connection for the claimed disabilities. Robinette v. Brown, 8 Vet. App. 69, 79 (1995). II. Evaluations of Skin Disorder and Hemorrhoids The veteran is seeking compensable disability ratings for his service-connected skin disorder and hemorrhoids. While this appeal involves the initial ratings assigned for the disabilities following a grant of service connection, the evidence of record shows that these disabilities have been stable since service connection was granted, effective January 1, 1993. Therefore, there is no basis for the assignment of staged ratings. See Fenderson v. West, 12 Vet. App. 119 (1999) (in a claim involving disagreement with the initial rating assigned following a grant of service connection, separate ratings can be assigned for separate periods of time, based on the facts found). VA determines disability evaluations through a schedule of ratings which is based on the average impairment of earning capacity resulting from specific service-connected disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. In order to qualify for a higher evaluation than he is currently assigned, the veteran must have a disability which more nearly approximates the criteria required for the next higher evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The regulations which are for application in determining the disability evaluation which should be assigned for each service-connected disability are contained in 38 C.F.R. Part 4, Schedule for Rating Disabilities. The Board notes that the rating schedule does not provide specific criteria for the veteran's diagnosed skin disorder. When an unlisted condition is encountered it can be rated under a closely related disease or injury in which not only the function affected, but the anatomical localization and symptomatology, are closely analogous. 38 C.F.R. § 4.20. The veteran's skin disorder has been evaluated under Diagnostic Code 7806, which provides ratings for eczema. Eczema with slight, if any, exfoliation, exudation or itching, if on a non-exposed surface or small area, is rated at zero percent. Eczema with exfoliation, exudation or itching, if involving an exposed surface or extensive areas, is rated as 10 percent disabling. 38 C.F.R. § 4.118, Diagnostic Code 7806. At the August 1998 VA dermatology examination, the veteran was noted to have a small, slightly pigmented area on his chest that was not itching at the time. The veteran testified that his skin disorder consisted of an occasional rash that itched, and that would come and go. Thus, the evidence does not support a finding that his skin disorder involves an exposed surface or extensive area nor that it results in constant exudation or itching, extensive lesions, or marked disfigurement. Therefore, a compensable rating is not warranted for his skin disorder. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.7, 4.118, Diagnostic Code 7806. Hemorrhoids, whether external or internal, which are mild or moderate are assigned a noncompensable (0 percent) rating. External or internal hemorrhoids which are large or thrombotic, irreducible, with excessive redundant tissue, evidencing frequent recurrences, are rated 10 percent disabling. External or internal hemorrhoids with persistent bleeding and with secondary anemia, or with fissures, are rated 20 percent disabling. 38 C.F.R. § 4.114, Diagnostic Code 7336. In this case, the evidence shows that the veteran has recurrent hemorrhoids. However, the medical evidence shows that his hemorrhoids are no more than moderate. He has testified that he has recurrent hemorrhoids that bleed during flare-ups. The medical evidence shows that he has occasional hemorrhoidal flare-ups, but it does not show that he has hemorrhoids that are large or thrombotic and irreducible, with excessive redundant tissue. Thus, a compensable rating for hemorrhoids is not warranted. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.7, 4.114, Diagnostic Code 7336 In reaching these determinations, the Board has considered the complete medical history of the disabilities in question as well as the current manifestations and the effect the disabilities may have on the earning capacity of the veteran. 38 C.F.R. §§ 4.1, 4.2. Further, the Board has carefully reviewed the evidence of record; however, the Board does not find the evidence so evenly balanced that there is doubt on any material issue. 38 U.S.C.A. § 5107. ORDER Service connection for a cardiovascular disorder including hypertension, a sinus disorder, a kidney disorder, bilateral hearing loss, and tinnitus are denied. Entitlement to compensable evaluations for a skin disorder and hemorrhoids are denied. REMAND In regards to the claim for service connection for a gastrointestinal disorder, the veteran's service medical records show that he was seen on a number of occasions for complaints of gastrointestinal discomfort and chest pains that were attributed to gastritis and gastroesophageal reflux disease. He was treated with Tagamet and Mylanta. The VA general medical examination in February 1993 showed that the veteran's digestive system was within normal limits and the pertinent diagnosis was a history suggestive of hiatal hernia. At his personal hearing, the veteran testified that he had problems with his stomach in service, and that the military doctors told him that he had a hiatal hernia. He also reported that he continued having such problems and began taking medication from the VA Medical Center in Kansas City, Missouri, for chronic reflux symptoms beginning in 1993. The VA requested these records in October 1995 and again in November 1995 and was informed that they were unable to locate the veteran's records. At the hearing, the veteran had a medication bottle with him for Ranitidine. The prescription, dated in January 1995, was for chronic reflux symptoms and was from the VA Medical Center in Kansas City. VA outpatient treatment records regarding treatment of reflux symptoms and this prescription are not in the veteran's claims file. After reviewing the evidence of record, the Board finds that additional development is required prior to a final appellate determination on the issue of entitlement to service connection for a gastrointestinal disorder. In light of these circumstances, the case is REMANDED to the RO for the following action: 1. The RO should request that the veteran provide the names and addresses of all health care providers, private and VA, from whom he has received medical treatment for his gastrointestinal disorders. The RO should take the appropriate steps to obtain any additionally identified medical records. Efforts to obtain these records must be documented and any additional evidence received should be associated with the claims folder. 2. The RO should request all medical records from the VA Medical Center in Kansas City from 1993 to the present and provide the appropriate documentation in the claims file if such records are unobtainable. If the records are unavailable from the VA, the RO should inform the veteran of this fact and request that if he has any copies of his VA medical records, he should submit that evidence. 3. Thereafter, if the veteran's claim for service connection for gastrointestinal disorder is well grounded, the RO should take the appropriate action to provide the veteran with a VA gastrointestinal examination to determine the nature and extent of any current gastrointestinal disorders. The examiner should be requested to review the veteran's claims file. All indicated testing should be conducted and all clinical manifestations should be reported in detail. Based upon examination and review of the record, the examiner should proffer an opinion, with supporting analysis, as to whether it is at least as likely as not that any currently identified gastrointestinal disorder which may be found is related to the veteran's complaints and symptoms in service. Reasons and bases for all conclusions should be provided. 4. After completion of the above, the RO should review the record and readjudicate the veteran's claim of entitlement to service connection for a gastrointestinal disorder. Following review, if any determination made remains unfavorable to the appellant, a supplemental statement of the case which sets forth the evidence received since the most recent statement of the case should be issued to him. He should be given the appropriate period of time in which to respond. Thereafter, the case should be returned to the Board for further consideration, if in order. The purpose of this remand is to obtain additional medical information and afford the appellant due process. No action is required of the appellant until he receives further notice. TRUDY S. TIERNEY Acting Member, Board of Veterans' Appeals