Citation Nr: 0003087 Decision Date: 02/08/00 Archive Date: 02/15/00 DOCKET NO. 94-21 936 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Pittsburgh, Pennsylvania THE ISSUES 1. Entitlement to service connection for flat feet. 2. Entitlement to service connection for hypertension. 3. Entitlement to service connection for a colon disorder. 4. Entitlement to service connection for hemorrhoids. 5. Entitlement to service connection for an umbilical hernia. 6. Entitlement to service connection for a urinary tract infection. 7. Entitlement to service connection for kidney disease. 8. Entitlement to service connection for tinea unguium. 9. Entitlement to service connection for thoracic outlet syndrome. 10. Entitlement to a permanent and total disability rating for pension purposes. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Robert A. Leaf, Counsel INTRODUCTION The appellant had active military service from October 1967 to May 1969. This appeal to the Board of Veterans' Appeals (Board) arises from a January 1993 rating decision of a regional office (RO) of the Department of Veterans Affairs (VA). By that rating decision, the RO denied entitlement to all the issues listed on the title page of this decision. The veteran submitted a timely appeal with respect to that rating decision. The Board notes that the January 1993 rating decision also denied service connection for a psychiatric disorder, including post-traumatic stress disorder (PTSD). The appellant timely appealed that adverse determination. Additional medical data were subsequently added to the record, and the RO entered a decision on September 7, 1999 granting service connection for PTSD and assigning a 50 percent rating. The case was certified for appeal to the Board on September 10, 1999 as to the issues listed on the title page of this decision. The RO informed the veteran of the rating decision by letter of September 24, 1999. In the informal hearing presentation of October 1999, the appellant's representative specified that the appellant wished to formally disagree with the RO's assignment of a 50 percent evaluation for PTSD. The Board notes that, based on current precedent decisions of the United States Court of Appeals for Veterans Claims (Court), a notice of disagreement (NOD) must be filed with the agency of VA which entered the determination with which disagreement is expressed. Nacoste v. Brown, 6 Vet. App. 439 (1994) and Beyrle v. Brown, 9 Vet. App. 24 (1996). In view of the procedural history discussed above, the Board refers to the RO the issue of entitlement to an evaluation greater than 50 percent for PTSD. It should be noted that, under governing criteria, the appellant has until September 23, 2001 to initiate an appeal as to the assignment of a 50 percent evaluation for PTSD by the submission of an NOD to the RO. 38 C.F.R. § 20.302 (1999). The decision which follows addresses all issues listed on the title page of this decision, except service connection for hemorrhoids. The issue of service connection for hemorrhoids is addressed in a remand at the end of this decision. FINDINGS OF FACT 1. The appellant has not submitted evidence sufficient to justify a belief by a fair and impartial individual that his claim for service connection for flat feet is plausible. 2. The appellant has not submitted evidence sufficient to justify a belief by a fair and impartial individual that his claim for service connection for hypertension is plausible. 3. The appellant has not submitted evidence sufficient to justify a belief by a fair and impartial individual that his claim for service connection for a colon disorder is plausible. 4. The appellant has not submitted evidence sufficient to justify a belief by a fair and impartial individual that his claim for service connection for an umbilical hernia is plausible. 5. The appellant has not submitted evidence sufficient to justify a belief by a fair and impartial individual that his claim for service connection for a urinary tract infection is plausible. 6. The appellant has not submitted evidence sufficient to justify a belief by a fair and impartial individual that his claim for service connection for kidney disease is plausible. 7. The appellant has not submitted evidence sufficient to justify a belief by a fair and impartial individual that his claim for service connection for tinea unguium is plausible. 8. The appellant has not submitted evidence sufficient to justify a belief by a fair and impartial individual that his claim for service connection for thoracic outlet syndrome is plausible. 9. Service connection is in effect for the appellant's PTSD, evaluated 50 percent disabling. 10. His nonservice-connected disabilities are as follows: an umbilical hernia, hereafter evaluated as 30 percent disabling; pes planus, currently evaluated as 10 percent disabling; left thoracic outlet syndrome, currently evaluated as 10 percent disabling; hypertension, hereafter evaluated as 10 percent disabling; a colon disorder, currently evaluated as noncompensable; hemorrhoids, currently evaluated as noncompensable; a urinary tract infection, currently evaluated as noncompensable; a kidney disorder, currently evaluated as noncompensable; and tinea unguium, currently evaluated as noncompensable. 11. His ratable disabilities have a combined evaluation of 80 percent. 12. The appellant was born in October 1947; has completed four years of high school; has occupational experience primarily in factory work and construction; and reports last having worked gainfully in 1982. 13. The appellant's innocently acquired disabilities are of sufficient severity as to permanently preclude him from engaging in substantially gainful employment consistent with his age, education and occupational experience. CONCLUSIONS OF LAW 1. The claim for service connection for flat feet is not well-grounded. 38 U.S.C.A. § 5107(a) (West 1991). 2. The claim for service connection for hypertension is not well-grounded. 38 U.S.C.A. § 5107(a) (West 1991). 3. The claim for service connection for a colon disorder is not well-grounded. 38 U.S.C.A. § 5107(a) (West 1991). 4. The claim for service connection for an umbilical hernia is not well-grounded. 38 U.S.C.A. § 5107(a) (West 1991). 5. The claim for service connection for a urinary tract infection is not well-grounded. 38 U.S.C.A. § 5107(a) (West 1991). 6. The claim for service connection for kidney disease is not well-grounded. 38 U.S.C.A. § 5107(a) (West 1991). 7. The claim for service connection for tinea unguium is not well-grounded. 38 U.S.C.A. § 5107(a) (West 1991). 8. The claim for service connection for thoracic outlet syndrome is not well-grounded. 38 U.S.C.A. § 5107(a) (West 1991). 9. The veteran is permanently and totally disabled for pension purposes due to all of his ratable disabilities. 38 U.S.C.A. §§ 1502, 1521, 5107 (West 1991); 38 C.F.R. §§ 3.340, 3.342, 4.17 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Factual Background No pertinent abnormalities were noted on an examination in October 1967 for service entrance. Blood pressure was 124/74. Service medical records disclose that the veteran presented at a clinic on December 5, 1968, complaining of burning with urination for the past week. A urinalysis showed 15-20 white blood cells per high power field. On a subsequent clinic visit on December 11, 1968, he again complained of burning with urination, and a urinalysis now showed 5-8 red blood cells per high power field. A complaint of burning on urination was again voiced on December 14, 1968. A January 30, 1969 treatment notation indicates a complaint that the urine was dark in color. In May 1969, in connection with an examination for service separation, the veteran again complained of burning on urination, as well as a discharge. The initial assessment was that he had nonspecific urethritis. Thereafter, a specimen from a smear of the urethral discharge revealed many white blood cells and many bacteria. The assessment was mixed infection. On the separation examination performed in May 1969, the veteran reported that he had experienced a kidney infection; he did not specify when the reported kidney infection had occurred. Clinical inspection disclosed that blood pressure was 120/80. A urinalysis was negative, as was a chest x-ray. The cardiovascular system, abdomen and viscera, anus and rectum, genitourinary system, feet, skin, and neurologic status were found to be normal. Service medical records are negative for flat feet, hypertension, a colon disorder, an umbilical hernia, tinea unguium, or left thoracic outlet syndrome. Associated with the claims folder are VA outpatient records of January 1988 through May 1992. In January 1988, the veteran reported that he had developed a fungus infection of the toenails while in Vietnam. In October 1988, he noted that an umbilical hernia had developed, two years before, after lifting. Clinical inspection indicated the presence of an umbilical hernia and fissure in ano. In November 1991, the veteran referred to his bowel movements as being very small and hard, with much pushing involved with bowel movements. On clinical inspection, no external or internal hemorrhoids or anal fissures were seen. It was noted that the umbilicus extended outward and was tense. The impressions included umbilical hernia, possibly secondary to increased abdominal pressure from alcoholic liver disease; and rectal/anal soreness and abrasions, probably due to rock hard stools and straining during bowel movements. An original claim for compensation and pension was received in May 1992. The appellant stated that he had completed high school. He referred to occupational experience in the construction industry. A VA general medical examination was conducted in July 1992. The veteran indicated that hypertension had been present since 1969. He took no medication for hypertension. He stated that he had a history of recurrent urinary tract infections which had started, in 1968, while he was in Vietnam. He denied urinary tract problems currently. He remarked that surgery for a thoracic outlet condition had been performed in 1975 or 1976. Clinical findings were recorded. Blood pressure was 162/90. A small umbilical hernia was found to be reducible. Both feet were tender to palpation. There was no evidence of callus formation or soft tissue swelling. No neurological deficits were elicited on examination. The diagnoses included recurrent urinary tract infection; pes planus, both feet; tinea unguium, bilaterally; umbilical hernia; essential hypertension; and status post left thoracic outlet syndrome. Clinical records reflect that the veteran received treatment for PTSD at the Readjustment Counseling Center from June 1989 to September 1992. In therapy, the veteran explored various matters, including confronting alcoholism and maintaining sobriety, dealing with recollections of Vietnam, coping with anger, and achieving good self-image. A VA psychiatric examination was performed in August 1995. The veteran related that he was first employed in factory work after he left service. He later had jobs in construction. He now worked part-time as a helper in landscaping and maintenance. He indicated that he had left a number of jobs because he had trouble relating to authority figures and because he could not stand following orders. He admitted to extensive alcohol abuse. He noted that he experienced intermittent depression. Mental status interview showed that he was quite apprehensive and anxious. Mood was somewhat labile. Remote and recent memory seemed intact. The veteran seemed to have difficulty concentrating. The diagnoses on Axis I were dysthymic disorder; and alcohol dependence. The examiner assigned a Global Assessment of Functioning (GAF) score of 55, with a score of 60 in the past year. The assessment was that dysthymic disorder produced moderate to severe social and occupational impairment, while alcohol abuse produced mild to moderate loss of function. Several examinations were performed by VA during the period from July to September 1997. On cardiovascular examination, the diagnoses were essential hypertension and hypertensive cardiovascular heart disease. On urologic examination, the veteran stated that he had developed a kidney infection in Vietnam; he denied genitourinary complaints currently. The genitourinary examination was normal. Additionally, clinical findings of a nephrologic examination were negative. On examination of the feet, the veteran referred to foot pain, greater on the left than the right. The impressions were that he had symptoms of heel spurs and fasciitis; and tinea of the nails of the feet. Further, on general medical examination, it was found that the veteran had an umbilical hernia, which was a half-dollar in size, and not reducible. He complained of pain when it was touched. The umbilical hernia was out all of the time; it was not strangulated. Clinical inspection elicited slight weakness of the left arm and hand. The diagnoses included hypertension, on medication; and weakness of the left arm due to outlet syndrome on the left; with a notation that the first rib had been removed. On rectal examination, the veteran reported that he had experienced intermittent rectal bleeding all of his life, including during basic training in 1967 and 1968. Additionally, clinical findings indicated the presence of an umbilical hernia. The examiner noted that the rectum was so tight that the vault could barely be inspected. No cause was found for reported loose stools. The assessment was that the veteran probably had hemorrhoids. Further, the examiner pointed out that the veteran might possible have colitis, but remarked that a diagnosis of colitis required the performance of a colonoscopy and laboratory tests. A psychiatric examination was arranged by VA in August 1997. According to the veteran's history, he had experienced a hard time adjusting to civilian life after his return from the military. He could not get along with people, and became resentful as he believed others were pushing him. He resorted to excessive drinking. He had tried at least 30 jobs, but had a very poor work record. Since 1982, he had not been able to return to any gainful employment. On mental status interview, the veteran was easily excitable and nervous, showing some increased psychomotor activity. Affect was somewhat constricted; mood was low. He indicted that he had a "short fuse." He was found to be oriented to time, place and person. He had no problems with past or recent recollection. The diagnoses on Axis I were PTSD with features of anxiety disorder; and alcohol abuse. The examiner assigned a GAF score of 50, with a GAF in the past year of 65. The assessment was that persistent symptoms of anxiety, tension, depressed mood, a low level of tolerance for anxiety and stress, and inability to relate to others effectively were factors which had adversely affected the veteran's social and occupational functional capacity. Currently, he was deemed unemployable. VA outpatient records, dated from November 1997 to August 1998, reflect the veteran's treatment for various disorders, including hypertension and PTSD. It was reported that the veteran received Fosinopril and Verapamil. The following blood pressure readings were obtained: November 24, 1997- 169/96; November 25, 1997-194/88; December 19, 1997- 163/106; February 13, 1998-162/102 and 170/104; and March 26, 1998-164/100. Psychological testing on March 26, 1998 showed that the veteran was manifesting multiple neurotic symptoms, including depression, nervousness, anxiety, weakness, fatigue, lack of initiative, and a pervasive lack of self-confidence and self-esteem. Also noted was that the veteran's score on a specific test for depression suggested moderate to severe depression. Subsequent treatment entries through August 1998 reflect the veteran's visits to a mental health clinic where he reported that he was irritable and had problems with temper; that he had sleep difficulties; and that he was somewhat anxious and depressed. An examination by a board of two VA psychiatrists was performed in February 1999. On mental status interview, the veteran was alert and coherent. He was found to be depressed. There was no indication of hallucinations or delusions. He complained of difficulty concentrating or remembering things. The diagnoses on Axis I were PTSD and history of alcohol abuse. A GAF score of 41-50 was assigned. II. Legal Analysis A. Service Connection Claims Other Than for Hemorrhoids The threshold question in this case is whether the appellant has presented well-grounded claims for the multiple disorders for which service connection is sought. A well-grounded claim is one which is plausible. If he has not presented a well-grounded claim, the claim must fail and there is no further duty to assist in the development of the claim. 38 U.S.C.A. § 5107; Murphy v. Derwinski, 1 Vet. App. 78 (1990). A well-grounded claim requires more than an allegation; the claimant must submit supporting evidence. Furthermore, the evidence must justify a belief by a fair and impartial individual that the claim is plausible. Tirpak v. Derwinski, 2 Vet. App. 609 (1992). As will be explained below, the Board finds that the claims for service connection listed on the title page of this decision, with the exception of service connection for hemorrhoids, are not well-grounded. Evidentiary assertions by the appellant must be accepted as true for the purposes of determining whether a claim is well- grounded, except where the evidentiary assertion is inherently incredible or when the fact asserted is beyond the competence of the person making the assertion. King v. Brown, 5 Vet. App. 19 (1993). Also, where the determinative issue involves either medical causation or a medical diagnosis, competent medical evidence is required to establish a well-grounded claim. Grottveit v. Brown, 5 Vet. App. 91 (1993). In order for a claim to be well-grounded, there must be competent evidence of a current disability (medical diagnosis), of incurrence or aggravation of a disease or injury in service (lay or medical evidence), and of a nexus between the in-service injury or disease and the current disability (medical evidence). Caluza v. Brown, 7 Vet. App. 498 (1995). Under the applicable criteria, service connection may be granted for disability resulting from disease or injury incurred in or aggravated by wartime service. 38 U.S.C.A. § 1110 (West 1991). In addition, certain chronic diseases, including cardiovascular-renal disease, and essential hypertension, may be presumed to have been incurred during service if they first become manifest to a compensable degree within one year of separation from wartime service. 38 U.S.C.A. §§ 1101, 1112, 1113, (West 1991); 38 C.F.R. §§ 3.307, 3.309 (1999). In order for service connection to be established, there must not only be evidence of a disease or injury during service, there must also be evidence of a current disability which is attributable to such disease or injury. Without such evidence, there can be no valid claim. Rabideau v. Derwinski, 2 Vet. App. 141 (1992); Brammer v. Derwinski, 3 Vet. App. 223 (1992). With respect to a urinary tract infection and kidney disease, the veteran, as a lay person, is competent to state that he had genitourinary symptoms during service; in fact, service medical records indicate complaints of burning with urination. Here, however, there is no objective evidence that the veteran currently has any chronic disorder characterized by kidney or urinary tract symptoms. As to these two disorders, the first and third Caluza requirements for establishing well-grounded claims of service connection have not been met. Turning to disorders other than a urinary tract infection or kidney disease, the Board notes that all three requirements set forth in Caluza must be met in order for a claim to be well-grounded. With respect to flat feet, hypertension, an umbilical hernia, tinea unguium and left thoracic outlet syndrome, the Board finds that the first requirement of Caluza is satisfied since there is competent medical evidence that the veteran currently has these disorders. With respect to a colon disorder, the medical evidence, although very equivocal, arguably suggests that the veteran may currently have a colon disorder. Accordingly, as to a colon disorder, the Board also finds that the first requirement of Caluza is satisfied. The second Caluza requirement is met in that the veteran, as a lay person, is competent to state that he experienced inservice symptoms involving various parts of the body. Either explicitly or implicitly, he has stated that, during service, he noticed that his feet appeared to be flat; that he had an infection of the toenails of the feet; that he had a protrusion about the umbilical area; that he experienced some type of arterial vascular symptoms; and that he experienced some type of neurologic symptoms involving the left thoracic region. However, the third Caluza requirement, that there be a nexus between inservice disease or injury and a current disability, is not met since there is currently no competent medical evidence linking current flat feet, hypertension, a colon disorder, an umbilical hernia, tinea unguium, or left thoracic outlet syndrome, to any incident or experience of the veteran's military service. At bottom, the veteran's assertions are the only evidence linking any of the multiple disorders for which service connection is sought to military service. As a lay person, he is not competent to offer a medical opinion regarding the diagnosis or etiology of a disorder. Espiritu v. Derwinski, 2 Vet. App. 492 (1992). No competent medical evidence has been presented showing that any of the disorders for which service connection is sought, other than hemorrhoids, had its onset in service. His lay assertion alone cannot render a claim well-grounded in a case that requires proof of medical causation. As previously noted, a claimant must submit supporting evidence that justifies a belief by a fair and impartial individual that his claim is plausible. As such evidence has not been presented, the claims of service connection for multiple disorders, other than service connection for hemorrhoids, are not well-grounded. B. A Permanent and Total Disability Rating for Pension Purposes The Board notes that the appellant's claim for a permanent and total disability rating for pension purposes is "well- grounded" within the meaning of 38 U.S.C.A. § 5107(a) (West 1991). That is, he has presented a claim which is plausible. The Board is also satisfied that all relevant facts have been properly developed and that no further assistance to the appellant is required to comply with the duty to assist mandated by 38 U.S.C.A. § 5107(a) (West 1991). The law authorizes payment of pension to a veteran of war who has the requisite service and who is permanently and totally disabled. 38 U.S.C.A. §§ 1502, 1521 (West 1991). Permanent and total disability ratings for pension purposes are authorized for disabling conditions not the result of the veteran's own willful misconduct. 38 C.F.R. § 3.342 (1999). Total disability will be considered to exist where there is present an impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. Permanence of total disability will be taken to exist when such impairment is reasonably certain to continue throughout the life of the disabled veteran. 38 C.F.R. § 3.340 (1999). Additionally, where the evidence of record establishes that an applicant for pension who is basically eligible fails to meet the disability requirements based on the percentage standards of the VA Schedule for Rating Disabilities (Rating Schedule) but is found to be unemployable by reason of his or her disability or disabilities, age, occupational background, and other related factors, a permanent and total disability rating on an extraschedular basis may be approved. 38 C.F.R. § 3.321(b) (1999). A review of the record indicates that the RO has assigned a 50 percent evaluation for the appellant's service-connected PTSD. Additionally, the RO has assigned the following evaluations for nonservice-connected disabilities: pes planus, currently evaluated as 10 percent disabling; left thoracic outlet syndrome, currently evaluated as 10 percent disabling; hypertension, currently evaluated as noncompensable; a colon disorder, currently evaluated as noncompensable; hemorrhoids, currently evaluated as noncompensable; an umbilical hernia, currently evaluated as noncompensable; a urinary tract infection, currently evaluated as noncompensable; a kidney disorder, currently evaluated as noncompensable; and tinea unguium, currently evaluated as noncompensable. The Board has reviewed the entire evidentiary record and, with two exceptions, hypertension and an umbilical hernia, concurs with the ratings assigned by the RO for the veteran's multiple disorders. The appellant's umbilical hernia may be evaluated by analogy to an inguinal hernia under 38 C.F.R. § 4.114, Diagnostic Code 7338 (1999). A noncompensable rating is warranted for an inguinal hernia which is small, reducible, or without true hernia protrusion. A noncompensable rating is also warranted for an inguinal hernia which is not operated, but remediable. A 10 percent rating is warranted for an inguinal hernia which is postoperative, recurrent, readily reducible and well supported by truss or belt. A 30 percent rating is warranted for an inguinal hernia which is small, postoperative recurrent, or unoperated irremediable, not well supported by truss, or not readily reducible. As to an umbilical hernia, the Board notes that the disorder has increased somewhat in severity in recent years. Although the umbilical hernia remains small, it is no longer reducible, and the protrusion is always present. Manifestations of an umbilical hernia are now more consistent with the criteria for assignment of a 30 percent rating for an inguinal hernia. The appellant's hypertension is evaluated under 38 C.F.R. § 4.104, Diagnostic Code 7101. Effective January 12, 1998, the criteria for evaluating essential hypertension were amended, and new rating criteria were promulgated. When regulations concerning entitlement to a higher rating are changed during the course of an appeal, the appellant is entitled to a decision on the claim under criteria which are most favorable to the appellant. Karnas v. Derwinski, 1 Vet. App. 308 (1991). In its review of the percentage rating which the RO has assigned for the appellant's hypertension, the Board has considered both the old and new criteria for evaluating hypertension. A 10 percent rating is warranted for hypertensive vascular disease (essential hypertension) when diastolic pressure is predominantly 100 or more. NOTE (1): For the 40 percent and the 60 percent ratings under code 7101, there should be careful attention to diagnosis and repeated blood pressure readings. NOTE (2): When continuous medication is shown necessary for control of hypertension with a history of diastolic blood pressure predominantly 100 or more, a minimum rating of 10 percent will be assigned. 38 C.F.R. § 4.104, Diagnostic Code 7101 (effective prior to January 12, 1998). A 10 percent rating is warranted for hypertensive vascular disease (hypertension and isolated systolic hypertension) when diastolic pressure is predominantly 100 or more, or; when systolic pressure is predominantly 160 or more, or; minimum evaluation for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. NOTE: (1): Hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days. For purposes of this section, the term hypertension means that the diastolic blood pressure is predominantly 90mm or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160mm or greater with a diastolic blood pressure of less than 90mm. NOTE (2): Evaluate hypertension due to aortic insufficiency or hyperthyroidism, which is usually the isolated systolic type, as part of the condition causing it rather than by a separate evaluation. 38 C.F.R. § 4.104, Diagnostic Code 7101 (effective on and after January 12, 1998). Upon a review of the record, the Board concludes that appellant's essential hypertension has increased somewhat in severity in recent years. The appellant now requires medication to control the condition. Accordingly, he satisfies the requirement for assignment of a 10 percent evaluation, under both the old and new criteria for rating hypertension. Having conducted an evaluation of all service-connected and nonservice-connected disabilities, the Board now determines appellant now has a single disability ratable at least 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. In addition, if the evidence demonstrates that he is, in fact, unable to secure or follow a substantially gainful occupation as a result of his disabilities, then the appellant meets one of the "objective" standards for eligibility for a permanent and total disability rating for pension purposes. 38 U.S.C.A. § 1502(a)(1) (West 1991); 38 C.F.R. §§ 4.16, 4.17 (1999). A review of the record discloses that PTSD produces a significant adverse impact on the appellant's social and occupational functioning. The medical evidence shows that any dysthymic disorder is nondissociable from PTSD. Accordingly, the veteran's tension and depression must be regarded as part and parcel of his ratable psychiatric condition. A psychiatric examination in recent years demonstrated that the appellant has serious problems with temper control and has difficulty accepting authority. In turn, these problems of social adjustment have led to frequent job changes and an unstable work record. Additionally, the appellant's depression and tension, to some extent, impede his performance in the work place. The Board is aware that the appellant has a longstanding, serious problem with alcohol dependence. Under governing criteria, alcohol dependence is deemed a disability of willful misconduct origin, and its impact may not be considered in determining the extent of overall impairment for pension purposes. 38 C.F.R. § 3.301(c)(2) (1999). Nevertheless, medical evidence in its entirety shows that all of the above noted disorders, other than alcohol dependence, permanently preclude gainful employment compatible with the veteran's age, education and occupational experience. As such, a proper basis is afforded for granting a permanent and total disability rating for pension purposes. ORDER Entitlement to service connection for flat feet is denied. Entitlement to service connection for hypertension is denied. Entitlement to service connection for a colon disorder is denied. Entitlement to service connection for an umbilical hernia is denied. Entitlement to service connection for urinary tract infection is denied. Entitlement to service connection for kidney disease is denied. Entitlement to service connection for tinea unguium is denied. Entitlement to service connection for thoracic outlet syndrome is denied. Entitlement to a permanent and total disability rating for pension purposes is granted. REMAND With respect to the claim for service connection for hemorrhoids, a review of the record discloses that the veteran was examined at clinics during service for complaints of rectal bleeding. Clinical inspection at the time disclosed external hemorrhoids with a small posterior anal fissure. Subsequently, no hemorrhoids or fissures were reported on a VA examinations in November 1991 or July 1992. Thereafter, in September 1997, a VA examiner attributed the veteran's complaint of rectal bleeding to "probable" hemorrhoids; at the same time, however, the examiner noted that an adequate rectal examination had been difficult to perform. There is currently no medical opinion of record as to the etiology of hemorrhoids, if now present. However, in view of the clinical documentation of hemorrhoids during service, the fact that hemorrhoids are in the nature of a chronic disorder, and the fact that an adequate examination has not been conducted to rule in or rule out the current presence of hemorrhoids, the Board is of the opinion that the claim is potentially well-grounded. Under the circumstances, the case is REMANDED for the following actions: 1. The veteran should be requested to clearly identify non-VA medical sources which have provided treatment for hemorrhoids since service. Names, addresses and dates of treatment should be specified. After obtaining a consent to the release of medical records from the veteran, the RO should request copies of the medical records from all identified sources which are not already in the claims folder. As well, the RO should obtain all VA medical (inpatient and outpatient treatment) records of the veteran, not currently of record. All medical records obtained should be added to the claims folder. 2. Thereafter, the veteran should be afforded an examination to determine whether or not hemorrhoids are now present. All indicated special studies should be performed and clinical findings reported in detail. The claims folder, including a copy of this remand, must be made available to the examining physician prior to the examination, and he must state in his examination report that the claims folder has been reviewed. If it is found that the veteran has hemorrhoids, then the examiner should answer the following question: Is it at least as likely as not that a currently demonstrated hemorrhoid disorder had its onset in service? The claims folder and a copy of this remand order must be made available to the examiner for review prior to the examination. When the development requested above has been completed, the case should be further reviewed by the RO. If the benefit sought on appeal is not granted, the appellant and his representative should be furnished a supplemental statement of the case and afforded a reasonable time to reply thereto. Thereafter, the case should be returned to the Board for further appellate consideration, if in order. No action is required of the appellant until notified. The purpose of this remand is to obtain clarifying information. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded to the regional office. Kutscherousky v. West, 12 Vet. App. 369 (1999). 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 Appeals for Veterans Claims 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. 1999) (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. BRUCE E. HYMAN Member, Board of Veterans' Appeals