Citation Nr: 0004566 Decision Date: 02/22/00 Archive Date: 02/28/00 DOCKET NO. 94-04 826 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUES 1. Entitlement to service connection for a thoracic spine disorder. 2. Entitlement to service connection for rhinitis. 3. Entitlement to service connection for sinusitis. 4. Entitlement to service connection for residuals of a left cheek furuncle. 5. Entitlement to service connection for residuals of a right neck cyst. 6. Entitlement to a compensable evaluation for residuals of a fracture of the left distal tibia. 7. Entitlement to an increased evaluation for hypertrophic cardiomyopathy with ischemia, currently evaluated as 30 percent disabling. REPRESENTATION Appellant represented by: AMVETS ATTORNEY FOR THE BOARD S. D. Regan, Counsel INTRODUCTION The veteran had active service from June 1969 to June 1973 and from August 1973 to December 1992. This matter came before the Board of Veterans' Appeals (hereinafter "the Board") on appeal from a May 1993 rating decision of the St. Petersburg, Florida Regional Office which granted service connection for residuals of a fracture of the left distal fibula and for non-obstructive hypertrophic cardiomyopathy with a history of anterior and anteroseptal wall ischemia and assigned noncompensable disability evaluations for both disorders. Service connection was also denied for a thoracic spine disorder, rhinitis, sinusitis, residuals of a left cheek furuncle and for residuals of a right neck cyst. A December 1993 rating decision, in pertinent part, recharacterized the veteran's service-connected cardiovascular disorder as hypertrophic cardiomyopathy with ischemia and increased the assigned disability evaluation to 30 percent effective January 1, 1993. In November 1995, the veteran's claims file was transferred to the Jackson, Mississippi Regional Office (hereinafter "the RO"). In March 1997, the Board remanded this appeal to the RO to contact the veteran and inquire whether he still desired a travel board hearing before a member of the Board. The veteran has been represented throughout this appeal by AMVETS. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the veteran's appeal has been obtained by the RO. 2. Competent evidence reflecting the current existence of a thoracic spine disorder has not been presented. 3. Competent evidence reflecting the current existence of rhinitis has not been presented. 4. Competent evidence reflecting the current existence of sinusitis has not been presented. 5. The veteran's residuals of a left cheek furuncle have been reasonably shown to have had origins during active service. 6. The veteran's residuals of a right neck cyst have been reasonably shown to have had origins during active service. 7. The veteran's cardiovascular disorder is productive of no more than cardiomyopathy or arteriosclerotic heart disease with a workload of greater than 5 METs, but not greater than 7 METs, resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilation on electrocardiogram, echocardiogram, or X-ray. 8. The veteran's cardiovascular disorder, alternatively considered, is productive of no more than arteriosclerotic heart disease following typical coronary occlusion or thrombosis, or with a history of substantiated anginal attacks with ordinary manual labor feasible. CONCLUSIONS OF LAW 1. The claim for entitlement to service connection for a thoracic spine disorder is not well-grounded. 38 U.S.C.A. § 5107 (West 1991 & Supp. 1999). 2. The claim for entitlement to service connection for rhinitis is not well-grounded. 38 U.S.C.A. § 5107 (West 1991 & Supp. 1999). 3. The claim for entitlement to service connection for sinusitis is not well-grounded. 38 U.S.C.A. § 5107 (West 1991 & Supp. 1999). 4. Residuals of a left cheek furuncle were incurred in active service. 38 U.S.C.A. §§ 5107, 1110, 1131 (West 1991 & Supp. 1999); 38 C.F.R. § 3.303 (1999). 5. Residuals of a right neck cyst were incurred in active service. 38 U.S.C.A. §§ 5107, 1110, 1131 (West 1991 & Supp. 1999); 38 C.F.R. § 3.303 (1999). 6. The schedular criteria for an evaluation in excess of 30 percent for hypertrophic cardiomyopathy with ischemia have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991 & Supp. 1999); 38 C.F.R. Part 4, including §§ 4.3, 4.7 and Diagnostic Code 7005 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSION Initially, it is necessary to determine if the veteran has submitted well-grounded claims within the meaning of 38 U.S.C.A. § 5107(a) (West 1991 & Supp. 1999), and if so, whether the Department of Veterans Affairs (hereinafter "VA") has properly assisted him in the development of his claims. A "well-grounded" claim is one which is not implausible. Murphy v. Derwinski, 1 Vet.App. 78 (1990). A review of the record indicates that the veteran's claims for service connection for residuals of a left cheek furuncle and residuals of a right neck cyst as well as for an increased evaluation for his service-connected hypertrophic cardiomyopathy with ischemia are well-grounded and that all relevant facts have been properly developed. It is observed that pursuant to the October 1999 informal hearing presentation, the accredited representative noted that there was no indication that a travel board hearing scheduled for June 7, 1999 was held and requested that the veteran be contacted concerning whether he desired a hearing. The Board notes that pursuant to the May 1997 remand instructions, the RO notified the veteran in April 1997 regarding his request for a travel board hearing before a member of the Board, and indicated that if he did not want to wait for a travel board hearing he could elect one of the several alternative hearing options. The veteran apparently did not respond. In April 1999, the veteran was notified of a travel board hearing to be held on June 7, 1999. There is a notation in the claims file that the veteran was a "no show" for such hearing. The Board is of the view that a further remand, as to this matter, would be futile. The Board is satisfied, therefore, that the total clinical and other documentary evidence available is sufficient for appellate determination of the issues presently on appeal. As discussed below, the Board finds that the veteran's claims for service connection for a thoracic spine disorder, for rhinitis and for sinusitis are not well-grounded and that, therefore, there is no further duty to assist the veteran with development of such claims. I. Service Connection for a Thoracic Spine Disorder, Rhinitis and for Sinusitis Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110, 1131 (West 1991 & Supp. 1999). Additionally, where a veteran served ninety (90) days or more during a period of war or during peacetime service after December 31, 1946, and arthritis becomes manifest to a degree of 10 percent within one year from the date of termination of such service, such disease shall be presumed to have been incurred in service even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131 (West 1991 & Supp. 1999); 38 C.F.R. §§ 3.307, 3.309 (1999). The disease entity for which service connection is sought must be "chronic" as opposed to merely "acute and transitory" in nature. For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time as distinguished from merely isolated findings or a diagnosis including the word "chronic". Continuity of symptomatology is required where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. Where the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b) (1999). 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). The United States Court of Appeals for Veterans Claims (hereinafter "the Court") has held that in order for a claim for service connection to be well-grounded, there must be (1) competent evidence of a current disability; (2) proof as to incurrence or aggravation of a disease or injury in service; and (3) competent evidence as to a nexus between the inservice injury or disease and the current disability. See Caluza v. Brown, 7 Vet.App. 498 (1995). The veteran's service medical records indicate that he was seen in April 1972 with complaints of a strained back after playing basketball. The impression was lumbosacral strain. A March 1983 entry noted that the veteran reported that he had a problem with a stuffy nose. The assessment was nasal congestion. A May 1985 entry noted that the veteran was seen with complaints of post-nasal drainage and a cough at night. The assessment, at that time, was seasonal rhinitis. A February 1986 examination report noted that an X-ray showed that the veteran had mild scoliosis of the lower thoracic spine, but was otherwise within normal limits. There was a notation that the veteran's spine and other musculoskeletal systems were normal. A November 1989 treatment report noted an assessment of infraorbital edema, probably allergic. A November 1989 radiological report, as to the veteran's sinuses, indicated an impression that the findings supported bilateral maxillary antral disease. A December 1989 treatment entry noted an assessment of infraorbital swelling, resolved and sinus disease. A September 1990 entry noted that the veteran complained of chronic rhinitis/sinus, chronic post-nasal drip and recurrent hoarseness. The assessment was chronic rhinitis. A September 1990 radiological report, as to the veteran's sinuses, noted that the veteran had a history of chronic rhinitis with possible right maxillary sinusitis. The report indicated that there had been considerable clearing of the maxillary antrum from previous X-rays. An October 1990 consultation report noted that the veteran had had chronic rhinitis with a possible cyst of the right maxillary sinus. The assessment was chronic rhinitis. An April 1991 examination report included notations that the veteran's sinuses, spine and other musculoskeletal systems were normal. A March 1992 entry noted that the veteran complained of post- nasal drip and stuffy ears. The assessment was sinus congestion possibly due to allergy. The veteran underwent a VA general medical examination in March 1993. He reported a history of having sinusitis in the past. The examiner indicated that examination of the veteran's nose, sinuses, mouth and throat was normal. It was noted that the veteran reported that he had no knowledge of a thoracic spine condition and that he denied any symptoms referable to the upper back. The examiner reported that examination of the veteran's back revealed no muscle spasm or point tenderness. The examiner stated that the thoracic spine did not reveal any deformity on gross palpation. The neurological examination was normal. The diagnoses included history of sinusitis. The veteran underwent a VA cardiovascular examination in October 1993. There was no reference to rhinitis, sinusitis or to a thoracic spine disorder. May 1996 VA and February 1998 VA cardiovascular examination reports also did not refer to such disorders. The Board has made a careful longitudinal review of the record. It is observed that the veteran's service medical records indicate that he was seen in April 1972 with complaints of a strained back after playing basketball. The impression was lumbosacral strain. A February 1986 examination report noted that an X-ray showed that the veteran had mild scoliosis of the lower thoracic spine, but was otherwise within normal limits. There was a notation, at that time, that the veteran's spine and other musculoskeletal systems were normal. An April 1991 examination report also included a notation that the veteran's spine and musculoskeletal systems were normal. The Board notes that a March 1993 VA general medical examination report noted that the veteran reported that he had no knowledge of a thoracic spine condition and that he denied symptoms referable to the upper back. The examiner reported that examination of the veteran's back revealed no muscle spasm or point tenderness. The examiner also indicated that the veteran's thoracic spine did not reveal any deformity on gross palpation. The diagnoses referred to other disorders. Subsequent VA cardiovascular examination reports of record did not refer to any thoracic spine disorder. The Board observes that the medical evidence of record fails to indicate that the veteran suffers from a presently diagnosed thoracic spine disorder or that he suffered any increase in severity of any scoliosis of the thoracic spine during his period of service. 38 C.F.R. § 3.306 (1999). As to the veteran's claimed rhinitis and sinusitis, the Board observes that the veteran's service-medical records do indicate that he was treated for variously diagnosed sinus disorders during his period of service. A March 1983 treatment entry noted that the veteran reported that he had a problem with a stuffy nose and indicated an assessment of nasal congestion. A May 1985 entry noted that the veteran was seen with complaints of post-nasal drainage and a cough at night. The assessment, at that time, was seasonal rhinitis. A November 1989 radiological report, as to the veteran's sinuses, indicated an impression that the findings supported bilateral maxillary antral disease. A subsequent September 1990 radiological report, as to the veteran's sinuses, related that there had been considerable clearing of the maxillary antrum from the previous X-rays. Additionally, the Board notes that an October 1990 consultation report noted an assessment of chronic rhinitis and a March 1992 entry indicated an assessment of sinus congestion possibly due to allergy. Further, the Board observes that a March 1993 VA general medical examination report noted that the veteran reported a history of having sinusitis in the past. The examiner indicated that examination of the veteran's nose, sinuses, mouth and throat was normal. The diagnoses included history of sinusitis. The Board notes that the history of having sinusitis in the past, was apparently solely provided by the veteran. The Board observes that the Court has held that evidence which is simply information recorded by a medical examiner, unenhanced by any additional medical comment by the examiner, does not constitute "competent medical evidence" satisfying the Grotveit v. Brown, 5 Vet.App. 91 (1993) requirement. The Board also notes that although an examiner can render a current diagnosis based on his examination of the veteran, without a thorough review of the record, his opinion regarding etiology can be no better than the facts alleged by the veteran. See Swann v. Brown, 5 Vet.App. 229, 233 (1993). The Board observes that there is no indication that the examiner reviewed the record prior to noting such history. Additionally, the examiner did not diagnose the presence of rhinitis, sinusitis or any other present sinus disorder. Additionally, subsequent VA cardiovascular examination reports of record did not refer to such disorders. The Board notes that the veteran has not presented any competent evidence establishing that he presently suffers from rhinitis and sinusitis. The Board observes that a service connection claim must be accompanied by evidence which establishes that the claimant currently has the claimed disability. See Rabideau v. Derwinski, 2 Vet.App. 141, 144 (1992); see also Brammer v. Derwinski, 3 Vet.App. 223, 225 (1995) (absent "proof of a present disability there can be no valid claim"). As noted above, the clinical and probative evidence of record simply fails to indicate that the veteran presently suffers from rhinitis, sinusitis, or from any presently diagnosed thoracic spine disorder. Further, the Board notes that the veteran has alleged in statements on appeal that he presently suffers from such disorders which originated during his period of service. However, the veteran is not competent, as a lay person, to establish that he presently suffers from such disorders, in terms of offering a substantiating medical diagnosis, to assert medical causation, or to indicate any actual identifiable aggravation of any thoracic spine disorder during service. See Grotveit v. Brown, 5 Vet.App. 91, 93 (1993); Espiritu v. Derwinski, 2 Vet.App. 492, 495 (1992). The Board observes that it is certainly within the province of the veteran to report that he suffered from sinusitis, rhinitis and from a thoracic spine disorder during service. However, the credible and competent evidence of record does not adequately permit the diagnosing or otherwise recognizing the onset of such chronic disabilities during service, or otherwise relate the existence of such actual current disabilities to the veteran's period of service or indicate that there was any increase in severity of a preexisting thoracic spine disorder. Gregory v. Brown, 8 Vet.App. 563 (1996). The clinical and probative evidence of record simply fails to adequately indicate that the veteran presently suffers from the claimed disorders. Accordingly, in the absence of competent evidence establishing that the veteran suffers from the claimed disorders, the Board concludes that the veteran's claims for service connection for a thoracic spine disorder, rhinitis and sinusitis are not well-grounded. Further, the Board finds the information provided in the statement of the case and other correspondence from the RO sufficient to inform the veteran of the elements necessary to complete his application for service connection. Moreover, the veteran has not put the VA on notice of the existence of any specific, particular piece of evidence that, if submitted, might make the claim well- grounded. Robinette v. Brown, 8 Vet.App. 69 (1995). Although the RO did not specifically state that it denied the veteran's claims on the basis that they were not well grounded, the Board concludes that this was not prejudicial to the veteran. See Edenfield v. Brown, 8 Vet.App 384 (1995) (en banc) (when the Board decision disallowed a claim on the merits where the Court finds the claim to be not well grounded, the appropriate remedy is to affirm, rather than vacate, the Board's decision, on the basis of nonprejudicial error). The Board, therefore, concludes that denying the appeal on these issues because the claims are not well grounded is not prejudicial to the veteran. See Bernard v. Brown, 4 Vet.App. 384 (1993). II. Service Connection for Residuals of a Left Cheek Furuncle and for Residuals of a Right Neck Cyst The veteran's service medical records indicate that he was seen in January 1982 for a furuncle on the right neck secondary to an ingrown hair. The assessment was a furuncle. A May 1982 entry noted that the veteran complained of a mass on the right neck. The examiner reported that there was a pustula like one-half cm mass on the right neck. The assessment was a cyst. There was a notation that the cyst was duly excised. A subsequent May 1982 entry noted that the veteran was seen for follow-up of a cyst on the right neck which was resolving well. A October 1983 entry noted that the veteran complained of a sore on the left cheek. The examiner noted that there was a one and one-half cm erythematous, indurated lesion in the left cheek area. The assessment was a furuncle of the left cheek. A subsequent October 1983 entry noted that there was a two by two cm firm lesion, erythematous over the veteran's left cheek. The assessment was a furuncle of the left cheek. An additional October 1983 entry indicated an assessment of a furuncle with secondary cellulitis of the left face. An October 1983 hospital narrative summary noted a final diagnosis of furuncle of the left cheek. It was noted that no procedures were undertaken at that time. A November 1983 entry noted that there was some increase in the pustula and more puffiness at the border of the lesion below the eye. It was noted that a stab wound to the pustula was performed with minimal white exudate and some blood. The assessment, at that time, was a furuncle of the left cheek. Another November 1983 entry also indicated an assessment of furuncle of the left cheek, persistent. A later November 1983 consultation report noted that the pus drained spontaneously that morning. A February 1986 examination report noted that the veteran had been diagnosed with a furuncle of the left cheek and was hospitalized and treated with medications for four days. An April 1991 examination report noted that the veteran had pseudofolliculitis barbae and folliculitis. The veteran underwent a VA general medical examination in March 1993. It was noted that the veteran had a history of sebaceous cysts over his body some of which were incised and drained in the past. The diagnoses included "history of sebaceous cyst". The veteran underwent a VA cardiovascular examination in October 1993. There was no reference to residuals of a left cheek furuncle or to residuals of a right neck cyst. May 1996 and February 1998 VA cardiovascular examination reports also did not refer to such disorders. The Board has weighed the evidence of record. It is observed that the veteran's service medical records indicate that he was treated for both a right neck cyst and a left cheek furuncle during his period of service. A May 1982 entry noted that the veteran complained of a mass on the right neck. The examiner reported that there was a pustula-like one-half cm mass on the right neck. The assessment was a cyst. There was a notation that the cyst was duly excised. A later May 1982 entry noted that the veteran was seen for a follow-up of the cyst on the right neck which was resolving well. Additionally, the Board notes that an October 1983 treatment entry noted that the veteran complained of a sore on the left cheek. The examiner indicated that there was a one and one-half centimeter erythematous indurated lesion in the left cheek area. The assessment was a furuncle of the left cheek. A subsequent October 1983 entry noted that there was a two by two cm firm lesion, erythematous over the veteran's left cheek and indicated a similar assessment. Further, a November 1983 entry noted that there was some increase in the pustula and more puffiness at the border of the lesion below the veteran's eye. It was noted that a stab wound was performed with minimal white exudate and some blood. The assessment, at that time, was a furuncle of the left cheek. A November 1983 consultation report noted that the pus drained spontaneously that morning. A February 1986 examination report noted that the veteran had been diagnosed with a furuncle of the left cheek and was hospitalized and treated with medication for four days. An April 1991 examination report indicated that the veteran had pseudofolliculitis barbae and folliculitis. Additionally, the Board observes that a March 1993 VA general medical examination report noted that the veteran had a history of sebaceous cysts over his body, some of which were incised and drained in the past. The diagnoses included "history of sebaceous cyst". The Board observes that the medical evidence of record clearly indicates that the veteran underwent an excision of a cyst of the right neck and a stab wound of a furuncle of the left cheek during service. Additionally, the March 1993 VA general medical examination report did refer to inclusion and sebaceous cysts which were incised and drained in the past. Therefore, the Board is of the view that to conclude otherwise than that the evidence is at least in equipoise as to whether residuals of a left cheek furuncle and residuals of a right neck cyst were incurred during the veteran's period of service would not withstand Court scrutiny. Accordingly, with resolution of reasonable doubt in favor of the veteran, the Board concludes that service connection for residuals of a left cheek furuncle and for residuals of a right neck cyst is warranted. III. Increased Evaluation for Hypertrophic Cardiomyopathy with Ischemia The Board notes that according to a recent decision of the United States Court of Appeals for Veterans Claims (hereinafter "the Court"), because this appeal ensues from the veteran's disagreement with the rating assigned in connection with his original claim, the potential for the assignment of separate, or "staged," ratings for separate periods of time, based on the facts found, must be considered. Fenderson v. West, 12 Vet.App. 119 (1999). As to the veteran's service-connected cardiovascular disorder, the RO has not assigned separate staged ratings. The Board observes that the veteran has not been prejudiced by the RO's referring to his claim, as to this matter, as an "increased [evaluation]" although the appeal has been developed from his original claim. In reaching the determination below, the Board has considered whether staged ratings should be assigned. The Board concludes that the disability has not significantly changed throughout the appeal period and that a uniform evaluation is appropriate in this case. A. Historical Review The veteran's service medical records indicate that in February 1986, he was noted to have an abnormal electrocardiogram. A February 1986 consultation report noted that an abnormal electrocardiogram was found on a recent periodic physical evaluation showing right ventricular hypertrophy and other nonspecific T wave changes. The assessment was possible mild asymptomatic pulmonary outflow obstruction with pulmonic or subpulmonic stress. A September 1986 consultation report noted an assessment of hypertrophic nonobstructive cardiomyopathy. An April 1991 examination report noted that the veteran had nonobstructive hypertrophic cardiomyopathy, asymptomatic with a normal stress thallium. It was noted that an electrocardiogram could not rule out inferior ischemia, but was unchanged from the previous electrocardiogram. The veteran underwent a VA general medical examination. It was noted that he had a history of hypertrophic cardiomyopathy diagnosed in 1986. The veteran indicated that he occasionally had chest pains and tingling in the fingers. The examiner reported that an examination revealed that the veteran's heart sounds were of regular rate and rhythm without murmur or gallop. Blood pressure readings ranged from 110 to 126 systolic and 76 to 86 diastolic. The diagnoses included cardiomyopathy. In May 1993, service connection was granted for non- obstructive hypertrophic cardiomyopathy with a history of anterior and anteroseptal wall ischemia. A noncompensable disability evaluation was assigned effective January 1, 1993. B. Increased Evaluation Disability evaluations are determined by comparing the veteran's present symptomatology with the criteria set forth in the Schedule for Rating Disabilities. 38 U.S.C.A. § 1155 (West 1991 & Supp. 1998); 38 C.F.R. Part 4 (1998). The Board notes that the regulations governing the evaluation of cardiovascular disorders were amended as of January 12, 1998. See 62 FEDERAL REGISTER 65207 (1997) (to be codified at 38 C.F.R. §§ 4.100-4.102). The Board observes that the regulations applicable as of January 12, 1998, are more favorable to the pending claim for an increased rating. Therefore, the Board concludes that the veteran's claim will be evaluated under the new regulations governing cardiomyopathy and arteriosclerotic heart disease. See Karnas v. Derwinski, 1 Vet.App. 308, 313 (1991) (when there has been a change in an applicable regulation after a claim has been filed, but before final resolution, the regulation most favorable to the claimant must be applied). The regulations in effect as of January 12, 1998, provide that a 30 percent evaluation is warranted for cardiomyopathy with a workload of greater than 5 METs, but not greater than 7 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilation on electrocardiogram, echocardiogram, or X-ray. A 60 percent evaluation requires more than one episode of acute congestive heart failure in the past year, or; a workload of greater than 3 METs, but not greater than 5 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent. 38 C.F.R. Part 4, Diagnostic Code 7020 (1999). The regulations in effect as of January 12, 1998 also provide that a 30 percent evaluation is warranted for arteriosclerotic heart disease with documented coronary artery disease with a workload of greater than 5 METs, but not greater than 7 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilation on electrocardiogram, echocardiogram, or X-ray. A 60 percent evaluation requires more than one episode of acute congestive heart failure in the past year, or; a workload of greater than 3 METs, but not greater than 5 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent. 38 C.F.R. Part 4, Diagnostic Code 7005 (1999). Under the regulations in effect prior to January 12, 1998, there was not a specific diagnostic code for cardiomyopathy. A 30 percent evaluation is warranted for arteriosclerotic heart disease with typical coronary occlusion or thrombosis, or with history of substantiated anginal attacks, when ordinary manual labor is feasible. A 60 percent evaluation is warranted following a typical history of acute coronary occlusion or thrombosis, or with a history of substantiated repeated anginal attacks, when more than light manual labor is not feasible. 38 C.F.R. Part 4, Diagnostic Code 7005 (1997). Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (1999). The veteran underwent a VA cardiovascular examination in October 1993. It was noted that the veteran complained of chest pain, retrosternal and exertional, which radiated to his left arm at times and was described as numbness and pain which was relieved usually with rest. The veteran also complained of shortness of breath on mild to moderate exertion. The veteran denied any palpitation, dizziness or syncope as well as any history of myocardial infarction in the past. The examiner reported that the veteran's blood pressure was 104/78 and that his pulse was 78 and regular. It was noted that an electrocardiogram showed normal sinus rhythm with left ventricle hypertrophy with secondary ST and T wave abnormalities. There were diffuse symmetrical T wave inversions in the anterior and inferior leads. It was noted that a stress test was positive for ischemia. The diagnoses included hypertrophic cardiomyopathy, symmetrical, apical pattern with no outflow tract obstruction and the need to rule out artery disease. A December 1993 rating decision recharacterized the veteran's service-connected cardiovascular disorder as hypertrophic cardiomyopathy with ischemia and increased the assigned disability evaluation to 30 percent effective January 1, 1993. The 30 percent disability evaluation has remained in effect. The veteran underwent an additional VA cardiovascular examination in May 1996. He reported that he had a sense of tightness with occasional pericardial pain. The veteran indicated that at times, even without exertion, he would have pain radiating down the left arm. It was noted that the veteran did have chronic dyspnea, rarely at rest, and that he could walk about 4 to 5 blocks before he had to rest because of shortness of breath. The examiner noted that the veteran's blood pressure was 113/78 and his pulse was 76. The examiner reported that examination of the heart revealed a normal rate and rhythm with no audible murmurs. The examiner noted that there was palpable cardiomegaly with a point of maximum impulse in 1 centimeter beyond the midclavicular line in the fifth interspace. It was reported that an electrocardiogram showed biatrial enlargement, biventricular hypertrophy and marked ST abnormality. The diagnoses included arteriosclerotic heart disease with cardiomyopathy, NYHA classification 3, with symptoms occurring even at rest and no hypertension found. The examiner commented that he did not believe that a stress test was indicated. He stated that an adequate diagnosis was compatible with the history and electrocardiogram findings and chest X-ray findings with dyspnea and angina on exertion and at times occurring at rest. The veteran underwent a VA cardiovascular examination in February 1998. He had complaints of tightness in his chest on a stressful day. The veteran indicated that the tightness would occur below the left clavicle on the left side of the neck and that he would have severe numbness in the left arm. He stated that sometimes the symptoms would last for several days and the frequency was twice a month. It was noted that such symptoms did not prevent the veteran from doing his activities of daily living or working. The veteran also complained of shortness of breath on exertion and reported that he could walk about 50 or 100 yards. The examiner reported that that the veteran would have dyspnea on exertion if he walked 50 to 100 yards. The examiner reported that the veteran's blood pressure was 120/80 with a point of maximum impulse not palpable. It was noted that the left heart border was not enlarged on percussion/auscultation. S1 and S2 were normal and there was no murmur on exertion or at rest. There was no S3 or S4. The examiner reported that there was no cardiac arrhythmia and no evidence of congestive heart failure. The examiner indicated that an electrocardiogram showed left ventricular hypertrophy with strain. There was symmetrical T wave inversion from lead V2 to V6 and 23ABF indicative of apical hypertrophy. RS ratio and V1 was more than one, indicating right bundle branch pattern or right ventricular hypertrophy. A February 1998 chest X-ray indicated an impression of no acute disease and no changes since 1996. In an addendum, the examiner reported that an echocardiogram was performed and was consistent with apical hypertrophy. A stress test viewed good exercise tolerance. The examiner reported that the veteran completed five minutes, forty-eight seconds in stage II of the Bruce protocol, achieving 93 percent of the maximum heart rate in seven minutes. There was no chest pain, arrhythmias, or shortness of breath present. The examiner noted that in view of the baseline, ST-T changes, the stress test could not be interpreted for ischemia. The diagnoses included hypertrophic cardiomyopathy, apical hypertrophy and New York Heart Association Classification, Class IIB. In a March 1998 addendum, the examiner indicated that during the stress test the maximum work load achieved was 7. The Board has made a careful longitudinal review of the record. It is observed that the clinical and other probative evidence of record fails to indicate that the veteran suffers from symptomatology productive of manifestations warranting more than a 30 percent evaluation under the new regulations. 38 C.F.R Part 4, Diagnostic Codes 7005, 7020 (1999). The Board notes that such regulations indicate that a 30 percent evaluation is warranted for cardiomyopathy or arteriosclerotic heart disease with a workload of greater than 5 METs, but not greater than 7 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilation on electrocardiogram, echocardiogram, or X-ray. The most recent February 1998 VA cardiovascular examination report, to include a March 1998 addendum by the examiner, indicated that the veteran complained of tightness in the chest on a stressful day. He indicated that the tightness would occur below the left clavicle on the left side of the neck and that he would have severe numbness in the left arm. The veteran also reported that sometimes the symptoms would last several days with a frequency of twice a month. It was noted that the symptoms did not prevent the veteran from doing his activities of daily living or working. The examiner reported that the veteran would have dyspnea on exertion if he walked 50 to 100 yards. The examiner indicated that the veteran's blood pressure was 120/80 with a point of maximum impulse not palpable. It was noted that the left heart border was not enlarged on percussion/auscultation. The examiner further reported that there was no cardiac arrhythmia and no evidence of congestive heart failure. The examiner indicated that an electrocardiogram showed left ventricular hypertrophy with strain as well as symmetrical T wave inversion from lead V2 to V6 and 23ABF indicative of apical hypertrophy. RS ratio and V1 were more than one, indicating right bundle branch pattern or right ventricular hypertrophy. The examiner also reported that an echocardiogram was performed and was consistent with apical hypertrophy. The examiner stated that a stress test viewed good exercise tolerance. The diagnosed conditions included hypertrophic cardiomyopathy, apical hypertrophy and New York Heart Association Classification, Class IIB. In a March 1998 addendum, the examiner indicated that during the stress test the maximum work load achieved was 7. Additionally, the Board observes that a May 1996 VA cardiovascular examination report noted that the veteran reported that he had a sense of tightness with occasional precardial pain. The veteran indicated that at times, even without exertion, he would have pain radiating down the left arm. It was noted, at that time, that the veteran did have chronic dyspnea, rarely at rest, and that he could walk about 4 or 5 blocks before he had to rest because of shortness of breath. The examiner reported that the veteran's blood pressure was 113/78 and that examination of the heart revealed a normal rate and rhythm with no audible murmurs. The examiner stated that there was palpable cardiomegaly with a point of maximum impulse 1 cm beyond the midclavicular line in the 5th interspace. It was reported that an electrocardiogram showed biatrial enlargement, biventricular hypertrophy and marked ST abnormality. The diagnoses included arteriosclerotic heart disease with cardiomyopathy, NYHA Classification III, with symptoms occurring even at rest and no hypertension found. An October 1993 VA cardiovascular examination report noted that the veteran complained of chest pain, retrosternal and exertional, which radiated to his left arm at times and was described as numbness and pain. The diagnoses included hypertrophic cardiomyopathy, symmetrical, apical pattern with no outflow tract obstruction and the need to rule out artery disease. The Board observes that the medical evidence of record clearly fails to indicate that the veteran suffers from more than one episode of acute congestive heart failure in the past year, or; a workload of greater than 3 METs, but not greater than 5 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent as required for a 60 percent evaluation pursuant to the appropriate schedular criteria noted above. The February 1998 VA cardiovascular examination, to include the March 1998 addendum, indicated that the veteran did not have congestive heart failure and that the stress test viewed good exercise tolerance. Additionally, the examiner, in a March 1998 addendum to such examination, specifically indicated that during the stress test, the maximum work load achieved was 7 METs. The Board simply cannot conclude, based on the evidence of record, that the veteran suffers from symptomatology which more nearly meets the schedular criteria requisite to the assignment of a 60 percent evaluation. See 38 C.F.R. § 4.7 (1999). Additionally, to ensure that the veteran is not prejudiced by the Board's decision to evaluate him under the new regulations, the regulations in effect prior to January 12, 1998, will also be examined to determine if an increased evaluation could be made thereunder. See Bernard v. Brown, 4 Vet.App. 384 (1993). A 60 percent evaluation under the old criteria is for application following a typical history of acute coronary occlusion or thrombosis, or with a history of substantiated repeated anginal attacks, when more than light manual labor is not feasible. 38 C.F.R. Part 4, Diagnostic Code 7000 (1997). As noted above, the February 1998 VA cardiovascular examination report noted that the veteran's symptoms did not prevent him doing his activities of daily living or working. It was noted that the veteran would have dyspnea on walking 50 to 100 yards. However, the stress test showed a maximum workload of 7 METs and was considered to show good exercise tolerance. The Board observes that the evidence of record simply does not more nearly meet the criteria for a 60 percent evaluation pursuant to either the old or new regulations. Accordingly, the Board concludes an increased evaluation for the veteran's service-connected hypertrophic cardiomyopathy with ischemia is not warranted. Preliminary review of the record does not reveal that the RO expressly considered referral of the case to the Chief Benefits Director or the Director, Compensation and Pension Service for the assignment of an extraschedular rating under 38 C.F.R. § 3.321(b)(1) (1998). 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 extraschedular 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 United States Court of Veterans Appeals (Court) has held that the Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance; however, the Board is not precluded from raising this question, and in fact is obligated to liberally read all documents and oral testimony of record and identify all potential theories of entitlement to a benefit under the law and regulations. Floyd v. Brown, 9 Vet. App. 88 (1996). 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 record with these mandates in mind, the Board finds no basis for further action on this question. VAOPGCPREC. 6-96 (1996). ORDER Service connection for a thoracic spine disorder is denied. Service connection for rhinitis is denied. Service connection for sinusitis is denied. Service connection for residuals of a left cheek furuncle is granted. Service connection for a right neck cyst is granted. An increased evaluation for hypertrophic cardiomyopathy with ischemia is denied. REMAND The veteran asserts on appeal that he is entitled to an increased disability evaluation for his service-connected residuals of a fracture of the left distal tibia. The accredited representative has requested that this case be remanded in order to afford the veteran a VA examination. In reviewing the record, the Board notes that the veteran was last afforded a VA general medical examination in March 1993. At that time, the veteran reported that he had no residual symptoms as to his left distal fibular fracture in 1991. The examiner reported that the left ankle did not reveal any deformity, swelling, or joint laxity. The examiner noted that plantar flexion was 40 degrees and extension was 10 degrees. The diagnoses referred to other disorders. Additionally, in a September 1993 addendum, it was reported that as no joint problems were noted, an X-ray of the veteran's ankle was not taken pursuant to the March 1993 general medical examination. Such information would clearly be pertinent to assessing the disability evaluation to be assigned for the veteran's service-connected disorder. 38 C.F.R. Part 4, Diagnostic Codes 5262, 5270, 5271 (1999). Additionally, the Board notes that in his August 1993 substantive appeal, the veteran stated that his left ankle disorder had caused him considerable discomfort and pain since his separation from service. He reported that he had periods where he could not stand for a prolonged time on his foot because the ankle could not support it. The Board observes that the United States Court of Appeals for Veterans Claims (hereinafter "the Court") has held that in assigning a disability evaluation, the VA must consider the effects of the disability upon ordinary use, and the functional impairment due to pain, weakened movement, excess fatigability, or incoordination. DeLuca v. Brown, 8 Vet.App. 202 (1995); Schafrath v. Derwinski, 1 Vet.App. 589 (1991); 38 C.F.R. §§ 4.40, 4.45 (1995). The Court has also held that the Board is prohibited from reaching its own unsubstantiated medical conclusions. See Colvin v. Derwinski, 1 Vet.App. 171, 175 (1991). Further, when the medical evidence is inadequate, the VA must supplement the record by seeking an advisory opinion or ordering another medical examination. Halstead v. Derwinski, 3 Vet.App. 213 (1992). Given the nature of the veteran's contentions, the lack of a recent VA examination, to include X-ray reports and active and passive ranges of motion as to the veteran's left ankle, and in consideration of the Court's holdings in DeLuca, Schafrath, Colvin and Halstead, the Board concludes that an additional VA examination would be helpful in resolving the issue raised by the instant appeal. The Board observes that treatment records subsequent to February 1998 have neither been requested nor incorporated into the record. The Board is of the view that an attempt should be made to obtain any recent treatment records of possible pertinence to the veteran's claim. In light of the VA's duty to assist the veteran in the proper development of his claim as mandated by the provisions of 38 U.S.C.A. § 5107(b) (West 1991) and as interpreted by the United States Court of Veterans Appeals (hereinafter "the Court") in Littke v. Derwinski, 1 Vet.App. 90, 92-93 (1990), this case is REMANDED for the following action: 1. The RO should notify the veteran that he may submit additional evidence and argument in support of his claim. See Kutscherousky v. West, 12 Vet. App. 369 (1999). 2. The RO should request that the veteran provide information as to the medical facilities at which he received inpatient and outpatient treatment pertaining to his service-connected disorder from February to the present. Upon receipt of the requested information, the RO should contact the identified facilities and request that all available pertinent clinical documentation be forwarded for incorporation into the record. 3. The RO should schedule the veteran for a VA orthopedic examination in order to determine the present nature and severity of his service-connected residuals of a fracture of the left distal tibia. All indicated tests and studies, to include X-ray studies, should be accomplished and the findings then reported in detail. The examiner should specifically indicate, in degrees, the extent to which there is any limitation of motion of the left ankle to include the active and passive ranges of motion and any limitation of function of the parts affected by limitation of motion. Normal motion capabilities should also be specified. The claims folder must be made available to the examiner for review prior to the examination. 4. Following completion of the foregoing, the RO must review the claims folder and ensure that all of the foregoing development actions have been conducted and completed in full. If any development is incomplete, appropriate corrective action is to be implemented. Specific attention is directed to the examination report. If the examination report does not include fully detailed descriptions of pathology or adequate responses to the specific opinions requested, the report must be returned for corrective action. 38 C.F.R. § 4.2 (1995) ("if the [examination] report does not contain sufficient detail, it is incumbent upon the rating board to return the report as inadequate for evaluation purposes."). Green v. Derwinski, 1 Vet.App. 121, 124 (1991); Abernathy v. Principi, 3 Vet.App. 461, 464 (1992); and Ardison v. Brown, 6 Vet.App. 405, 407 (1994). 5. Following completion of the above and following any additional development deemed necessary, the RO, in a rating decision, should reconsider the issue on appeal giving consideration to any additional evidence obtained. A supplemental statement of the case should also be prepared and issued. 6. This claim must be afforded expeditious treatment by the RO. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Veterans Appeals for additional development or other appropriate action must be handled in an expeditious manner. See The Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 302, 108 Stat. 4645, 4658 (1994), 38 U.S.C.A. § 5101 (West Supp. 1998) (Historical and Statutory Notes). In addition, VBA's ADJUDICATION PROCEDURE MANUAL, M21-1, Part IV, directs the ROs to provide expeditious handling of all cases that have been remanded by the Board and the Court. See M21-1, Part IV, paras. 8.44- 8.45 and 38.02-38.03. When the requested action has been completed, and if his claim continues to be denied, the veteran should be afforded a reasonable period of time in which to respond to a supplemental statement of the case. Thereafter, subject to current appellate procedures, the case should be returned to the Board for further appellate consideration if appropriate. The veteran need not take any action unless he is further informed. The purpose of this REMAND is to allow for further development of the record. No inference should be drawn from it regarding the final disposition of the veteran's claim. While regretting the delay involved in remanding this case, it is felt that to proceed with a decision on the merits at this time would not withstand Court scrutiny. JEFF MARTIN Member, Board of Veterans' Appeals