Citation Nr: 0004703 Decision Date: 02/23/00 Archive Date: 02/28/00 DOCKET NO. 98-20 888 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Louisville, Kentucky THE ISSUES 1. Entitlement to service connection for a right ankle disorder. 2. Entitlement to service connection for arthritis of multiple joints. 3. Entitlement to service connection for hepatitis. 4. Entitlement to service connection for hemorrhoids. 5. Entitlement to an initial compensable disability evaluation for a scar on the right index finger. 6. Entitlement to an initial compensable disability evaluation for a scar on the right ankle. 7. Entitlement to an initial compensable evaluation for a scar on the forehead. 8. Entitlement to an initial disability evaluation in excess of 10 percent for gastrointestinal reflux. 9. Entitlement to an initial compensable disability evaluation for bilateral flat feet. 10. Entitlement to an initial compensable evaluation for hearing loss of the left ear. 11. Entitlement to a compensable evaluation pursuant to 38 C.F.R. § 3.324. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Robert W. Legg, Counsel INTRODUCTION This matter comes before the Board of Veterans' Appeals (BVA or Board) from a June 1998 decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Louisville, Kentucky, which denied the benefits sought. The veteran retired in August 1998 after more than 26 years of active service. Initially, one issue developed for appellate review, entitlement to service connection for hypertension, was granted in a May 1999 hearing officer's decision. In this regard, this benefit sought has been granted in full, and is no longer on appeal. That same hearing officer's decision granted a 10 percent evaluation for gastrointestinal reflux. As this is not the highest evaluation available under the diagnostic criteria, it is still a viable issue for appellate consideration by the Board. AB v. Brown, 6 Vet. App. 35, 38 (1993). The veteran's claims for service connection for a right ankle disorder and for arthritis for multiple joints, his claims for compensable evaluations for scars on the right index finger, right ankle, and forehead, as well as his claim for an initial compensable evaluation for hearing loss of the left ear, are discussed in the REMAND portion of this decision following the ORDER below. FINDINGS OF FACT 1. The veteran underwent surgery on his right ankle during service. 2. The veteran was diagnosed with arthritis of multiple joints during service. 3. The veteran was exposed to hepatitis during service. 4. There is no competent medical evidence of record establishing that the veteran's exposure to hepatitis constitutes a disability, nor is there evidence of any manifestation of the exposure to hepatitis other than on laboratory examination of the blood. 5. The veteran has not presented evidence that he currently suffers from chronic hemorrhoids. 6. The veteran's service-connected gastrointestinal reflux is manifested by daily pain in his epigastrium with slight nausea, but is not manifested by dysphagia, pyrosis, or regurgitation, and the veteran's health has not been impaired by this disorder. 7. The veteran's service-connected bilateral flat feet are manifested by pain with standing or running, but are not manifested by inward bowing of the tendo achilles or by objective evidence of marked deformity. 8. The veteran has been assigned a compensable (10 percent) disability evaluation for service-connected gastrointestinal reflux. CONCLUSIONS OF LAW 1. The veteran's claim for service connection for a right ankle disorder is well grounded. 38 U.S.C.A. § 5107(a) (West 1991). 2. The veteran's claim for service connection for arthritis of multiple joints is well grounded. 38 U.S.C.A. § 5107(a) (West 1991). 3. The veteran has not submitted a well-grounded claim of entitlement to service connection for hepatitis. 38 U.S.C.A. § 5107(a) (West 1991). 4. The veteran has not submitted a well-grounded claim of entitlement to service connection for hemorrhoids. 38 U.S.C.A. § 5107(a) (West 1991). 5. The preponderance of the evidence is against an initial disability evaluation in excess of 10 percent for gastrointestinal reflux. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 3.321(b), 4.1-4.40, 4.114, Diagnostic Code 7346 (1999). 6. An initial 10 percent evaluation, but no higher evaluation, is warranted for bilateral flat feet. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 3.321(b), 4.1-4.40, 4.71a, Diagnostic Code 5276 (1999). 7. A 10 percent disability evaluation under 38 C.F.R. § 3.324 for multiple noncompensable service-connected disabilities is precluded by the terms of that regulation. 38 C.F.R. § 3.324 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The veteran contends that he incurred a right ankle disorder, arthritis, exposure to hepatitis, and hemorrhoids, in service. The veteran also contends that his service- connected disabilities are more severely disabling than the current evaluations reflect. The veteran further contends that he is entitled to a compensable evaluation under 38 C.F.R. § 3.324 for his multiple noncompesnable service- connected disabilities. I. Service Connection Claims Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by a veteran's active service. 38 U.S.C.A. §§ 1110, 1131 (West 1991); 38 C.F.R. § 3.303 (1999). However, the threshold question in any claim for VA benefits is whether the claim is well grounded. 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); Robinette v. Brown, 8 Vet. App. 69, 73 (1995). A well grounded claim is "a plausible claim, one which is meritorious on its own or capable of substantiation. Such a claim need not be conclusive but only possible to satisfy the initial burden of § [5107]." Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). To establish a well-grounded claim for service connection, a veteran must demonstrate the incurrence or aggravation of a disease or injury in service, the existence of a current disability, and a nexus between the in-service injury or disease and the current disability. Medical evidence is required to prove the existence of a current disability and to fulfill the nexus requirement. Lay or medical evidence, as appropriate, may be used to substantiate service incurrence. Epps v. Gober, 126 F.3d 1464 (1997). With respect to a chronic disability subject to presumptive service connection, such as arthritis, evidence that the chronic disorder was manifested to a compensable degree within the prescribed period is sufficient to establish evidence of the required nexus. Traut v. Brown, 6 Vet. App. 498 (1994). The chronicity provision of 38 C.F.R. § 3.303(b) is applicable where the evidence shows that a veteran had a chronic condition in service or during an applicable presumption period and still has such condition. Such evidence must be medical unless it relates to a condition as to which lay observation is competent. If the chronicity provision is not applicable, a claim may still be well grounded or reopened on the basis of 38 C.F.R. § 3.303(b) if the condition is observed during service or any applicable presumption period, continuity of symptomatology is demonstrated thereafter, and competent evidence relates the present condition to that symptomatology. Savage v. Gober, 10 Vet. App. 488, 498 (1997). A. Right ankle disorder A September 1989 entry into service medical records reflects that the veteran had complaints of right lateral ankle pain. He was diagnosed with a strain. A July 1994 periodic examination report noted that the veteran had chronic right ankle pain, and was to be seen for a follow-up consultation as a result. In July 1994, the veteran reported to a military clinician that he had had right ankle pain for the previous seven months. Objectively, the veteran's right ankle was tender, but the anterior drawer test was negative. Lateral impingement was diagnosed. A September 1994 entry again noted tenderness, and that the veteran was five weeks post ankle scope. The military physician commented on the record that it was too early to decide if surgery would be beneficial. The veteran was noted to have had an operation on his right ankle at the time of his retirement examination in February 1998. However, reports of such surgery are not affiliated with the service medical records. In May 1998, the veteran was provided a VA examination. The veteran's relevant history was reviewed and noted by the examiner. Objectively, there was full range of motion of both ankles, but there was tenderness over the lateral malleolus of the right ankle. X-rays of the right ankle were normal. The examiner stated that there was insufficient clinical evidence "at this time" to warrant a diagnosis of any acute or chronic disorder, or residuals thereof, associated with ankle pain. The examiner did note a history of impingement syndrome, right ankle. In February 1999, the veteran was provided a hearing before an RO hearing officer. The veteran testified that he injured his ankle in the mid-1990s during the winter. He further related that he had surgery on his ankle during service, and that the surgeon who performed the procedure informed him that he would have pain later. Finally, the veteran did acknowledge that he had full range of motion of the ankle. In light of the above, the Board finds that the veteran has submitted a well-grounded claim for service connection for a right ankle disorder. In this respect, the veteran clearly had a disorder noted during service, which ultimately led to some form of surgery, and he currently has tenderness in this ankle. Thus, the veteran's claim is well-grounded, even though the VA examiner was unable to assign a diagnosis in the absence of records more specifically identifying the nature of the surgery. Therefore, the claim is REMANDED for development consistent with the duty to assist. 38 U.S.C.A. § 5107(a). B. Arthritis of multiple joints Service medical records dated November 1995, July 1996, and June 1997 reflect that the veteran was diagnosed with degenerative joint disease. In a February 1998 retirement examination report, it was noted that the veteran had degenerative arthritis of the knees, ankles and elbows. In May 1998, the veteran was provided a VA examination. The veteran informed the examiner that he had been told that he had degenerative joint disease of the elbows and a history of bone chips in his right elbow. Other history was related to the examiner, which was consistent with service medical records. X-rays of the elbows, knees, ankles and feet showed that each set of joints was normal. The examiner stated that there was insufficient evidence to show that the veteran had any joint abnormality. The examiner stated that there was insufficient clinical evidence "at this time" to warrant a diagnosis of any acute or chronic disorder, or residuals thereof, associated with elbow pain, knee pain, or ankle pain. The veteran testified before an RO hearing officer in February 1999. The veteran testified that arthritis was diagnosed during service, and that more recently pain had increased. In light of the above in-service diagnosis of arthritis, the Board finds that the veteran's claim for service connection for arthritis of multiple joints is well grounded. However, as there was not a clear diagnosis of arthritis at the time of his May 1998 VA examination, the Board also finds that further development is required before an informed decision can be made on this claim. C. Hepatitis A September 1996 service medical record entry reflected that the veteran had a history of exposure to hepatitis B, and had a mild elevation of a liver function test. A February 1998 blood work-up noted that the veteran was positive for exposure to the hepatitis B. The veteran denied having a history of hepatitis in his February 1998 retirement examination report. In May 1998, the veteran was provided a VA examination. The veteran related the above history to the examiner, who noted that the veteran had no known episodes of hepatitis or jaundice. There were no known or appreciable residuals from hepatitis. The only diagnosis was a history of exposure to hepatitis B. As noted above, the VA may only pay compensation for a "disability." 38 U.S.C.A. §§ 1110, 1117, 1131; 38 C.F.R. §§ 3.303; cf. 38 U.S.C.A. § 1153 (showing of aggravation requires an increase in disability). The Court has indicated it will rely on the definition of disability contained in 38 U.S.C.A. § 1701(1), which states: "The term 'disability' means a disease, injury, or other physical or mental defect." See Allen v. Brown, 7 Vet. App. 439, 444 (1995). However, the Court has limited this definition of disability "to refer to impairment of earning capacity due to disease, injury, or defect, rather than to the disease, injury, or defect itself." Allen, 7 Vet. App. at 448 (emphasis added). See also 38 C.F.R. § 4.1 (disability ratings reflect "average impairment in earning capacity"). In the veteran's case, although there is clinical evidence of exposure to hepatitis B during active military service, there is no evidence that this condition has resulted in any impairment in the veteran's earning capacity, or ever led to a diagnosis of hepatitis as a disease entity. Accordingly, the Board concludes that the veteran has failed to submit a medical diagnosis of a current disability required to well- ground his claim. See Epps, 126 F.3d at 1468; Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 144 (1992). Accordingly, in the absence of competent supporting medical evidence of a medically-diagnosed disability, the veteran's claim of entitlement to service connection for exposure to hepatitis is not well grounded, and must be denied. D. Hemorrhoids A December 1979 entry into service medical records reflects the veteran then had complaints of hemorrhoids. At the time of his February 1998 retirement examination, the veteran denied piles or rectal disease, and the examiner who actually inspected him found the veteran's anus and rectum normal. In May 1998, the veteran was given a VA examination. However, the examiner stated that the veteran deferred a rectal examination as he received a retirement examination in February 1998. The veteran was provided a hearing before an RO hearing officer in February 1999. The veteran informed the hearing officer that he had intermittent hemorrhoids. The veteran further testified that while he was provided a rectal examination in conjunction with his retirement examination, the examiner who performed the VA examination did not examine or inquire about hemorrhoids. In the absence of evidence of a claimed disability, there can be no valid claim. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992), Rabideau v. Derwinski, 2 Vet. App. 141, 144 (1992). As the veteran has not submitted evidence of a current medical diagnosis of chronic hemorrhoids, the Board must find that this claim is not plausible. Towards this end, the veteran testified that he was examined at the time of his retirement; as noted above, the veteran denied hemorrhoids at that time, and the examining physician did not note any abnormality pertaining to the rectum. While the veteran has disputed the assertion made by the VA examiner that the veteran declined an examination, such is not relevant in this claim, as he has not yet submitted evidence that would reflect the presence of a current disability. The veteran was informed, including by a December 1998 statement of the case, that medical evidence of a diagnosis of hemorrhoids was required, but the veteran has not submitted or identified additional medical evidence which might service to well-ground his claim. In light of the above, the Board must find that the veteran's claim is not well grounded, and must deny this claim on this basis. II. Increased Evaluations The veteran's claims for higher initial evaluations for his service-connected disabilities are well grounded within the meaning of 38 U.S.C.A. § 5107(a) (West 1991). The Court has held that a mere allegation that a service-connected disability has increased in severity is sufficient to render the claim well grounded. See Caffrey v. Brown, 6 Vet. App. 377, 381 (1994); Proscelle v. Derwinski, 2 Vet. App. 629, 632 (1992). Likewise, the Board can reasonably find that a challenge to an initial evaluation is well grounded. The Board is also satisfied that all relevant facts have been properly developed, and that the VA has fulfilled its duty to assist the veteran. In a recent decision, the Court distinguished between an appeal of a decision denying a claim for an increased rating from an appeal resulting from a veteran's dissatisfaction with an initial rating assigned at the time of a grant of service connection. Fenderson v. West, 12 Vet. App. 119 (1999). In the latter event, the Court, citing the VA's position, held that "staged" ratings could be assigned, in which separate ratings can be assigned for separate periods of time based on the facts found. This is a somewhat different view than that found in previously, in which the Court held that the current level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). In that case, however, an increased rating was at issue. As the veteran's claims for higher evaluations challenge the propriety of the initial evaluations assigned, the Board has considered the potential applicability of staged ratings. However, a review of the evidence does not reflect that the veteran's level of impairment attributable to any single disability has changed during the course of his claim, a staged rating does not appear to be warranted for any of his service-connected disabilities. The VA utilizes a rating schedule as a guide in the evaluation of disabilities resulting from all types of diseases and injuries encountered as a result of or incident to military service. The percentage ratings represent, as far as can practicably be determined, the average impairment in earning capacity resulting from such diseases and injuries and their residual conditions in civil occupations. See 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (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. Gastrointestinal reflux The veteran's service medical records contain numerous references to gastrointestinal difficulties. The veteran informed the physician who performed the February 1998 retirement examination that he used Pepcid AC for treatment. In May 1998, the veteran was provided a VA examination. The veteran informed the examiner that he used Pepcid or Tagamet as needed, usually once per day, although he had recently ran out of medication. As to current symptoms, the veteran related that he had daily pain in his epigastrium with slight nausea. The veteran denied vomiting of blood or emesis or any material, blood on the rectum or chronic diarrhea. The veteran did report that he would awaken at night due to pain from indigestion. Objectively, the veteran was 5 feet, 9 1/2 inches tall, and weighed 232 pounds, which was the maximum over the previous year. He was also described as well nourished and developed, and in no acute distress. His abdomen was flat, and bowel sounds were present in all four quadrants. There were no palpable masses, and his abdomen was non-tender. In February 1999, the veteran was provided a hearing before an RO hearing officer. He informed the hearing officer that he used Zantac and Pepcid AC for his gastrointestinal problems. The veteran also related that he had to avoid heavily seasoned foods, and that he had an increase in belching. The veteran's gastrointestinal reflux disease has been rated by analogy under 38 C.F.R. § 4.114, Diagnostic Code 7346, which evaluates hiatal hernias. Rating by analogy is permitted under 38 C.F.R. § 4.20. Diagnostic Code 7346 provides that the current 10 percent evaluation is warranted with the presence of two or more of the symptoms for the 30 percent evaluation, but with less severity. Persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health, warrants a 30 percent evaluation. The highest schedular evaluation, 60 percent, is warranted with symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. 38 C.F.R. § 4.114, Diagnostic Code 7346 (1999). In light of the above, the Board must find that the preponderance of the evidence is against an initial evaluation in excess of the currently assigned 10 percent evaluation. In this regard, the veteran has been characterized as well nourished, and there has been no evidence submitted that would establish that he has dysphagia, pyrosis or regurgitation. Indeed, the examiner who conducted the May 1998 VA examination stated that the veteran denied vomiting of blood or emesis of any material. There is no evidence that the veteran has sought treatment for substernal or arm or shoulder pain which has been medically attributed to his service-connected GI disability. Accordingly, the Board must find that the preponderance of the evidence is against an initial disability evaluation in excess of 10 percent. B. Bilateral flat feet The Board would note that the veteran was still on active duty at the time of his May 1998 VA examination. The veteran informed the examiner that he had developed pes planus (flat feet) during his active service. The veteran further explained that his feet would hurt if he ran more than a mile, but walking would not hurt his feet, but there was pain with standing for more than 15 minutes. He also related that while he used inserts in the past, he would more recently changed his boot size for relief. Objectively, posture and gait were normal, and range of motion of the ankles was also normal. His feet were characterized as flat, however. X- rays were normal. The veteran informed an RO hearing officer in February 1999 that he would use arch supports intermittently, but that they were less than effective. The veteran also testified that he had essentially constant numbness or burning in his feet, and that his feet were painful with manipulation. The veteran also testified that he had callosities. Acquired flatfoot is evaluated under Diagnostic Code 5276. That code provides that a noncompensable evaluation is warranted when manifestations are mild, as when symptoms are relieved by built-up shoe or arch support. Moderate manifestations, as demonstrated by weight-bearing line over or medial to great toe, inward bowing of the tendo achillis, pain on manipulation and use of the feet, bilateral or unilateral, warrant a 10 percent evaluation. A 20 percent rating is warranted for more severe symptomatology, including severe unilateral pes planus with objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, and characteristic callosities. A 30 percent rating is warranted for severe bilateral pes planus with objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, and characteristic callosities. 38 C.F.R. § 4.71a, Diagnostic Code 5276. In light of the above, the Board finds that evidence supports a 10 percent evaluation, as the veteran has consistently complained of foot pain which is unrelieved by use of arch supports. However, the preponderance of the evidence is against an initial evaluation in excess of 10 percent for the veteran's bilateral flatfeet. There is no evidence that the veteran's symptomatology of flat feet has varied during the initial evaluation period, so as to warrant a "staged" evaluation. Fenderson, supra. In this regard, the Board would note that the examiner who conducted the May 1998 VA examination did not find inward bowing of the tendo achilles, nor was there evidence of marked deformity. In particular, the veteran's feet were normal on radiologic examination. His gait, posture, stance, heel-to-toe walking, tandem walk, and deep knee bend were normal. The veteran himself stated he was able to run up to mile. Although the veteran testified that his feet were painful essentially at all times, including on manipulation, he did not testify that pain was accentuated on manipulation. Although the veteran testified that he had swelling, no swelling was noted on objective examination. The Board finds that the veteran's normal radiologic examination, normal gait, stance, and posture, and the ability to run as much as a mile are not consistent with a severe degree of flatfoot symptomatology in either foot. A rating in excess of 10 percent is not warranted. Conclusion Finally, the Board finds that none of the veteran's service connected disabilities present such "an exceptional or unusual disability picture as to render impractical the application of the regular rating schedule standards." 38 C.F.R. § 3.321(b)(1) (1999). In the absence of such factors such as marked interference with employment (that is, beyond that contemplated in the rating criteria) or frequent hospitalizations during the course of this claim, the Board finds that the criteria for submission for assignment of an extra-schedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996); Floyd v. Brown, 9 Vet. App. 88, 94-95 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). III. Compensable evaluation for multiple noncompensable service-connected disabilities Whenever a veteran is suffering from two or more separate permanent service-connected disabilities of such character as clearly to interfere with normal employability, even though none of the disabilities may be of compensable degree, the rating agency is authorized to apply a 10 percent rating, but not in combination with any other rating. 38 C.F.R. § 3.324 (1999). As noted in the introduction, a May 1999 hearing officer's decision granted a 10 percent evaluation for gastrointestinal reflux disease. The Board also notes that the decision herein also grants a 10 percent evaluation for moderate bilateral flatfoot. As the veteran has been assigned compensable evaluations for service-connected disability, the Board must find that a claim for a compensable evaluation for multiple noncompensable service-connected disabilities is precluded by the terms of the regulation, and that the claim must be dismissed. "[W]here the law and not the evidence is dispositive, the claim should be denied or the appeal to the BVA terminated because of the absence of legal merit or the lack of entitlement under the law." See Shields v. Brown, 8 Vet. App. 346, 351-352 (1995) [citing Sabonis v. Brown, 6 Vet. App. 426, 430 (1994)]. ORDER The veteran's claim for service connection for a right ankle disorder is well grounded, and, to that extent only, the appeal is granted. The veteran's claim for service connection for arthritis of multiple joints is well grounded, and, to that extent only, the appeal is granted. The veteran's claim for service connection for hepatitis is not well grounded. The veteran's claim for service connection for hemorrhoids is not well grounded. The claim for an initial disability evaluation in excess of 10 percent for gastrointestinal reflex is denied. A 10 percent initial disability evaluation for bilateral flatfeet is granted, subject to laws and regulations governing effective dates of monetary awards. The claim for a 10 percent disability evaluation based on multiple noncompensable service-connected disorders is denied. REMAND As noted above, the veteran's claims for service connection for a right ankle disorder and for arthritis of multiple joints are well grounded, thus triggering the duty to assist. 38 U.S.C.A. § 5107(a) (West 1991). The Board would note that while the veteran was diagnosed with arthritis during service, and indeed was placed on profile as a result, the May 1998 VA examination did not show that he had this disorder. In order to resolve what may appear to be conflicting diagnoses, the Board believes that further information is required before an informed decision can be made on this issue. The veteran underwent surgery on his right ankle during service; the veteran testified that he injured his ankle at Fort Knox, Kentucky. Complete treatment records pertaining to that surgery are not in the claims file or incorporated in service medical records. Subsequent to his February 1999 RO hearing, the RO contacted the Ireland Army Hospital at Fort Knox to obtain all treatment records from that facility. That facility responded in February 1999, informing the RO that the veteran's records were checked out. The facility informed the RO that the veteran might have records or have knowledge of their whereabouts. Thereafter, some records from the Ireland Army Hospital were obtained, but these did not pertain to the in-service surgery. The RO should again attempt to obtain the records from Ireland Army Hospital. If the records are still checked out, the RO should ask whether the records were checked out to the veteran or to someone else. If the records were not checked out by the veteran, the RO should ask the facility to assist in obtaining the records by mailing a notice to the individual/department/facility to which the records were released. If no records are available, the facility should be asked to obtain administrative records reflecting the type of right foot surgery performed. The Board notes there is no question that the veteran did have surgery on his right ankle; the only issue in dispute is whether he currently has any residual(s) of that surgery. The Board notes that the veteran testified, at his February 1999 personal hearing, that the residuals of scars of the right index finger, right ankle, and forehead, had increased in severity. Moreover, the veteran testified that each scar was tender and painful, at least at times. The Board also notes that the veteran testified that, although he had full range of motion of his right index finder, there was loss of dexterity and speed of that motion. Further examination of the scars, so that the evaluation can be reported in terms of the applicable rating criteria, is required. Finally, the RO's evaluation of the veteran's hearing loss was based solely on the results of an audiogram performed in conjunction with his retirement examination. The audiogram portion was apparently performed in April 1998, and showed hearing loss for VA compensation purposes in the left ear only. 38 C.F.R. § 3.385. However, no mention of a controlled speech discrimination test (Maryland CNC) is contained in this particular audiogram report. As the results of a speech discrimination test are required to effectively evaluate hearing loss, the Board finds that a VA audiological test is required before an informed decision can be made in evaluating the veteran's hearing loss. In light of the above, these issues are REMANDED to the RO for the following action: 1. The RO should again attempt to obtain the clinical records of the veteran's right foot surgery at Ireland Air Force Base, or alternative records of that surgery if the clinical records are still unavailable. 2. The RO is requested to provide the veteran with a comprehensive VA examination to determine whether he currently has of arthritis of multiple joints. Any and all indicated evaluations, studies, and tests deemed necessary by the examiner should be conducted, but must include X-rays of the joints affected. The examiner is also asked to reconcile the evidence reflecting assignment of a diagnoses of arthritis during service but not assigning that diagnosis at a VA examination performed shortly before the veteran's retirement. The complete rationale for each opinion expressed should be set forth. Since it is important "that each disability be viewed in relation to its history[,]" 38 C.F.R. § 4.1 (1999), the claims file must be made available to the examiner for review. 3. The RO is requested to provide the veteran with an appropriate VA examination to determine the full nature and extent of any right ankle disability. Any and all indicated evaluations, studies, and tests deemed necessary by the examiner should be accomplished, and all clinical findings should be reported in detail. In particular, the examiner is asked to comment on the presence or absence of any current disability attributable to the surgery performed on the right ankle during service. The examiner is also asked to perform range of motion studies of the right ankle, and to comment on the presence or absence of objective evidence of pain on manipulation and use, as well as other evidence of pain on use. All examination findings and a complete rationale for each opinion expressed should be set forth. The claims file must be made available to the examiner for review. 4. The RO is requested to provide the veteran with a VA audiological examination that comports with the criteria used to evaluate hearing loss. Any and all indicated evaluations, studies, and tests deemed necessary by the examiner should be accomplished. All examination findings and a complete rationale for each opinion expressed should be set forth, and must include sufficient results to effectively evaluate a hearing loss disability. The claims file must be made available to the examiner for review. 5. The RO is requested to provide the veteran with examination of the service- connected scars, and the results and findings on examination should be expressed in terms of the applicable rating criteria. Any and all indicated evaluations, studies, and tests deemed necessary by the examiner should be accomplished. In particular, the examiner should specify, as to each scar, whether the scar is tender, painful, limits motions, or the like. The examiner should described the veteran's subjective complaints of pain, incoordination, weakened movement, or the like, and should state whether there is objective evidence supporting the subjective complaints. All examination findings and a complete rationale for each opinion expressed should be set forth, and must include sufficient reasons and bases. 6. Thereafter, the RO is requested to readjudicate the veteran's claims for service connection and for a higher initial evaluations on the merits. If any benefit sought is not granted in full, the veteran and his representative should be furnished a supplemental statement of the case. Thereafter, the veteran and his representative should be afforded the appropriate opportunity to respond before the record is returned to the Board for further review. The purpose of this REMAND is to obtain additional development, and the Board does not intimate any opinion as to the merits of the case, either favorable or unfavorable, at this time. The appellant is free to submit any additional evidence he desires to have considered in connection with his current appeal. Kutscherousky v. West, 12 Vet. App. 369 (1999). No action is required of the appellant until he is notified. TRESA M. SCHLECHT Acting Member, Board of Veterans' Appeals