Citation NR: 9719299 Decision Date: 06/03/97 Archive Date: 06/13/97 DOCKET NO. 95-28 965 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Portland, Oregon THE ISSUES 1. Entitlement to service connection for a right ankle disorder. 2. Entitlement to service connection a foot condition diagnosed as chronic fungal dermatitis of the feet or onychomycosis. 3. Entitlement to service connection for hearing loss in the right ear. 4. Entitlement to service connection for a back disorder. 5. Entitlement to service connection for residuals of exposure to Agent Orange, claimed as breathing difficulties, upset stomach, dry hands, skin multiple lipomas, skin lesions, chloracne, slow healing of wounds, and sexual dysfunction. REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARING ON APPEAL Appellant and his spouse ATTORNEY FOR THE BOARD Daniel G. Krasnegor, Associate Counsel INTRODUCTION The veteran served on active duty from January 1952 to November 1973. This matter comes before the Board of Veterans’ Appeals (Board) on appeal of a May 1995 rating determination by the Department of Veterans Affairs (VA) Regional Office (RO). During his personal hearing at the RO in August 1996, the veteran presented testimony regarding residuals of a broken right leg. This matter has been neither prepared nor certified for appellate review and is referred to the RO for appropriate action. The issue of entitlement to service connection for a right ankle disorder will be addressed in the remand portion of this decision. CONTENTIONS OF APPELLANT ON APPEAL The veteran maintains that he injured his back in service jumping out of airplanes, that he has hearing loss in the right ear as the result of blast noise from weapons, that he developed a chronic foot fungus in Vietnam, and that as a result of exposure to Agent Orange, he has breathing difficulties, upset stomach, dry hands, skin multiple lipomas, skin lesions, chloracne, slow healing of wounds, and sexual dysfunction. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991 & Supp. 1996), has reviewed and considered all of the evidence and material of record in the veteran's claims file. Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that the record supports entitlement to service connection for hearing loss in the right ear, a foot condition diagnosed as chronic fungal dermatitis of the feet or onychomycosis, and residuals of Agent Orange claimed as chloracne and multiple lipomas. It is the decision of the Board that the preponderance of the evidence is against a grant of entitlement to service connection for a back disorder. It is the decision of the Board that the claim for service connection for residuals of Agent Orange exposure, claimed as breathing difficulties, upset stomach, dry hands, skin lesions, slow healing of wounds, and sexual dysfunction are not well grounded. FINDINGS OF FACT 1. The veteran has a history of noise exposure in service; he has been diagnosed with bilateral high frequency sensorineural hearing loss. 2. The veteran was treated for a fungal infection of the feet in service; he reports continuing symptoms from service to the present; he is presently diagnosed with a chronic fungal dermatitis of the feet or onychomycosis. 3. Chronic back pain began in 1980, more than six years after the veteran's separation from service. 4. A VA physician has attributed diagnosed chloracne and multiple lipomas to Agent Orange exposure. 5. The claim for service connection for residuals of Agent Orange exposure claimed as breathing difficulties, upset stomach, dry hands, skin lesions, slow healing of wounds, and sexual dysfunction is not supported by cognizable evidence showing that the claim is plausible or capable of substantiation. CONCLUSIONS OF LAW 1. Right ear hearing loss was incurred in service. 38 U.S.C.A. §§ 1110, 1131, 1154 5107 (West 1991 and Supp. 1996); 38 C.F.R. §§ 3.102, 3.303(a), 3.304 (1996). 2. A foot condition diagnosed as chronic fungal dermatitis of the feet or onychomycosis was incurred in service. 38 U.S.C.A. §§ 1110, 1131, 1154, 5107; 38 C.F.R. §§ 3.102, 3.303(a)(b), 3.304. 3. Lipomas and chloracne are secondary to Agent Orange exposure in service. 38 U.S.C.A. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303(a)(d), 3.309(e) (1996). 4. A back disorder was not incurred or aggravated in service. 38 U.S.C.A. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303(b). 5. The claim for service connection for residuals of Agent Orange exposure, claimed as breathing difficulties, upset stomach, dry hands, skin lesions, slow healing of wounds, and sexual dysfunction, is not well grounded. 38 U.S.C.A. § 5107. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Factual Background a. Fungal dermatitis of the feet and toes Service medical records demonstrate that beginning in October 1961, the veteran was treated for a number of dermatological disorders of the feet, including plantar warts, plantar callosities, and calluses. In August 1963, the veteran was treated for a tinea infection of the groin and feet, and in a report of medical history dated in January 1972, the veteran said that he had a history of athlete’s foot. In a March 1994 statement, the veteran recalled that he had contracted a foot fungus while in Vietnam. The veteran was afforded a VA examination in July 1994, at which time, he gave a history of chronic fungal dermatitis in his feet and toenails while in Vietnam. Physical examination revealed a lichenification on the soles of both feet with cracking of the skin and onychomycosis. The veteran was diagnosed with a chronic fungal dermatitis in the feet or onychomycosis. In a June 1995 statement, the veteran's spouse reported that the veteran's feet cracked and bled. During a personal hearing in August 1996 before RO personnel, the veteran stated that he had first noticed a fungus on his feet after his second tour of duty in Vietnam, and that he had sought treatment for the condition immediately after service and to the present. b. Hearing loss in the right ear Service administrative records show that the veteran received the Combat Infantry Badge. Audiometric testing while in service reflected the following findings in pure tone thresholds, in decibels: January 1968: Hertz 500 1000 2000 4000 Right Ear -5 -5 0 15 January 1972: Hertz 500 1000 2000 4000 Right Ear 5 5 5 35 In the report of medical examination accompanying the audiometric examination results, the veteran was diagnosed with high frequency hearing loss. August 1973: Hertz 500 1000 2000 4000 Right Ear 10 10 15 25 August 1973: Hertz 500 1000 2000 3000 4000 6000 Right Ear 0 15 0 10 5 0 The veteran argued that hearing loss was caused by his combat duty, in an April 1994 statement. During VA audiological examination in July 1994, the veteran gave a history of exposure to loud noises while in combat, and during training exercises. No post-service noise exposure was shown. On audiological evaluation, pure tone thresholds, in decibels, were as follows: Hertz 500 1000 2000 3000 4000 Right Ear 15 15 15 40 60 Speech audiometry revealed speech recognition ability of 96 percent bilaterally. The veteran was diagnosed with hearing within normal limits at the low and mid frequencies, with moderate severe, bilateral high frequency sensorineural hearing loss. In an August 1995 statement, the veteran's spouse indicated that the veteran had hearing problems, and during his RO hearing, the veteran stated hearing loss in the right ear had begun when he returned from Vietnam in service. He further said that he had been told that the hearing loss was due to blast of weapons. c. Residuals of Agent Orange exposure Of record is a DD Form 214, Armed Forces of the United States Report of Transfer or Discharge, showing that the veteran served in Vietnam from August 1966 to August 1967 and December 1969 to October 1970. Also of record is a July 1994 statement from a private physician to the effect that he had treated the veteran in February 1994 for benign nodules of the neck and scalp, which were excised. A VA Agent Orange protocol examination was accomplished in July 1994. Examination of the veteran revealed scattered semifirm lesions on the anterior chest wall, described as lipomas; multiple raised acne-type lesions on the face, papillomatous lesion on the mid back and purple-brown lesion on the anterior left parasternal area. Also noted were several cystic lesions on the palmar surface of the left hand and stasis pigmentary changes on the right leg below the knee. The veteran was diagnosed with chloracne, secondary to exposure to Agent Orange; status post removal of benign skin lesions, possibly secondary to Agent Orange; nevus lesions on the anterior chest wall and back, possibly secondary to Agent Orange; multiple lesions secondary to Agent Orange; chronic fungal dermatitis in the feet or onychomycosis, not related to Agent Orange; stasis dermatitis right leg, not related to Agent Orange. Of record is a private medical record, dated in September 1995, indicating that the veteran was being treated for sexual dysfunction. The examiner indicated that the veteran's sexual inadequacy might be related to a venous incompetence. d. Back disorder Service medical records reflect no treatment for or diagnosis of a back disorder in service. At his retirement examination in August 1973, the veteran reported that he had no history of recurrent back pain, and medical examination resulted in a finding that his musculoskeletal system and spine were normal. The veteran opined that he thought his back disorder might be to a limp associated with a right ankle disorder, in an April 1994 statement. A VA orthopedic examination took place in August 1994. At that time, the veteran said that he had had chronic low back pain since 1980. X-rays revealed degenerative arthritic changes with osteophyte formation at virtually every level of the lumbar spine and some narrowing of the intervertebral disc space at L5-S1. The examiner stated that in his opinion, there was no probable causal relationship between the veteran's back disorder and any problems he had with his right ankle. During his RO hearing in August 1996, the veteran attributed his back problems to jumping out of airplanes during more than 20 years of service. He also recalled that he may have been treated once in service for back pain. Laws and Regulations In order to be entitled to service connection for disease or disability, the evidence must reflect that a chronic disease or disability was either incurred in or aggravated by military service. 38 U.S.C.A. §§ 1110, 1131. Service connection connotes many factors but basically it means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces, or if preexisting such service, was aggravated therein. This may be accomplished by affirmatively showing inception or aggravation during service or through the application of statutory presumptions. Each disabling condition shown by a veteran's service records, or for which he seeks a service connection must be considered on the basis of the places, types and circumstances of his service as shown by service records, the official history of each organization in which he served, his medical records and all pertinent medical and lay evidence. Determinations as to service connection will be based on review of the entire evidence of record, with due consideration to the policy of the Department of Veterans Affairs to administer the law under a broad and liberal interpretation consistent with the facts in each individual case. 38 C.F.R. § 3.303(a). With chronic disease shown as such in service (or within the presumptive period under § 3.307) so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. This rule does not mean that any manifestation of joint pain, any abnormality of heart action or heart sounds, any urinary findings of casts, or any cough, in service will permit service connection of arthritis, disease of the heart, nephritis, or pulmonary disease, first shown as a clear-cut clinical entity, at some later date. 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." When the disease identity is established (leprosy, tuberculosis, multiple sclerosis, etc.), there is no requirement of evidentiary showing of continuity. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When 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). 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). Satisfactory lay or other evidence that an injury or disease was incurred or aggravated in combat will be accepted as sufficient proof of service connection if the evidence is consistent with the circumstances, conditions or hardships of such service even though there is no official record of such incurrence or aggravation. 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(d). When, after consideration of all the evidence, a reasonable doubt arises regarding service origin, such doubt will be resolved in favor of the appellant. 38 C.F.R. § 3.102. Impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3,000, 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385 (1996). If a veteran was exposed to an herbicide agent during active military, naval, or air service, the following diseases shall be service-connected if the requirements of § 3.307(a)(6) are met even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of § 3.307(d) are also satisfied. Chloracne or other acneform disease consistent with chloracne Hodgkin's disease Multiple myeloma Non-Hodgkin's lymphoma Acute and subacute peripheral neuropathy Porphyria cutanea tarda Prostate cancer Respiratory cancers (cancer of the lung, bronchus, larynx, or trachea) Soft-tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma) Note 1: The term "soft-tissue sarcoma" includes the following: Adult fibrosarcoma Dermatofibrosarcoma protuberans Malignant fibrous histiocytoma Liposarcoma Leiomyosarcoma Epithelioid leiomyosarcoma (malignant leiomyoblastoma) Rhabdomyosarcoma Ectomesenchymoma Angiosarcoma (hemangiosarcoma and lymphangiosarcoma) Proliferating (systemic) angioendotheliomatosis Malignant glomus tumor Malignant hemangiopericytoma Synovial sarcoma (malignant synovioma) Malignant giant cell tumor of tendon sheath Malignant schwannoma, including malignant schwannoma with rhabdomyoblastic differentiation (malignant Triton tumor), glandular and epithelioid malignant schwannomas Malignant mesenchymoma Malignant granular cell tumor Alveolar soft part sarcoma Epithelioid sarcoma Clear cell sarcoma of tendons and aponeuroses Extraskeletal Ewing's sarcoma Congenital and infantile fibrosarcoma Malignant ganglioneuroma Note 2: For purposes of this section, the term acute and subacute peripheral neuropathy means transient peripheral neuropathy that appears within weeks or months of exposure to an herbicide agent and resolves within two years of the date of onset. 38 C.F.R. § 3.309(e) (1996). In order to be granted service connection on a presumptive basis, the diseases listed at 38 C.F.R. § 3.309(e) shall have become manifest to a degree of 10 percent or more at any time after service, except that chloracne or other acneform disease consistent with chloracne, porphyria cutanea tarda and subacute peripheral neuropathy shall have become manifest to a degree of 10 percent or more within a year, and respiratory cancers within 30 years, after the last date on which the veteran was exposed to an herbicide agent during active service. 38 C.F.R. § 3.307(a)(6)(ii) (1996). A veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the Vietnam era and has a disease listed at § 3.309(e) shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. The last date on which such a veteran shall be presumed to have been exposed to an herbicide agent shall be the last date on which he or she served in the Republic of Vietnam during the Vietnam era. "Service in the Republic of Vietnam" includes service in the waters offshore and service in other locations if the conditions of service involved duty or visitation in the Republic of Vietnam. 38 C.F.R. § 3.307(a)(6)(iii) (1996). Analysis Initially, the Board has found that the veteran's claims for service connection for a back disorder, hearing loss in the right ear, a chronic fungal dermatitis of the feet, and residuals of Agent Orange claimed as lipomas and chloracne are well grounded pursuant to 38 U.S.C.A. § 5107 in that his claims are plausible, meritorious on their own or capable of substantiation. Murphy v. Derwinski, 1 Vet.App. 78, 81 (1990). Once it has been determined that a claim is well grounded, VA has a statutory duty to assist the veteran in the development of evidence pertinent to that claim. After reviewing the record, the Board is satisfied that all relevant, available evidence is on file and the statutory duty to assist the veteran in the development of evidence pertinent to those claims has been met. 38 U.S.C.A. § 5107. a. Fungal dermatitis of the feet and toes The evidence above shows that the veteran was treated in service for various skin problems involving the feet, including a tinea-type disorder and athlete’s foot. The veteran has reported that fungus infections began in service after his second tour of duty in Vietnam, and he and his wife have reported symptoms since then including cracking of the skin with bleeding. On VA examination in August 1994, the veteran was diagnosed with chronic fungal dermatitis of the feet or onychomycosis. As noted above, as the veteran has combat experience, in the absence of contradictory evidence, the Board is to accept his account of diseases or injuries incurred during that time, 38 C.F.R. § 3.304. As such, the Board accepts the veteran's statements regarding the start of his fungal infection while in Vietnam. The Board notes further that while a chronic disease involving dermatitis of the feet was not diagnosed in service, the veteran had indicated a continuity of symptomatology since that time, and is currently diagnosed with a skin condition of the feet described as a chronic fungal dermatitis of the feet or onychomycosis. Based on the veteran's reports of chronic symptoms since service, the currently diagnosed disease, the Board finds that a grant of service connection for a foot condition diagnosed as chronic fungal dermatitis of the feet or onychomycosis is in order. 38 U.S.C.A. § 1110, 1131; 38 C.F.R. § 3.303(b)(d). b. Hearing loss in the right ear To summarize the evidence above, the veteran served for over twenty years on active duty, with combat service. He reports that while in service, he was frequently exposed to loud noises from weapons. Service medical records show that while in service, the veteran was diagnosed with high frequency hearing loss, but did not have hearing loss for VA purposes in the right ear, 38 C.F.R. § 3.385. Nevertheless, a VA audiological examination conducted in July 1994 showed that the veteran did have hearing loss for VA purposes in the right ear. On that examination, a VA examiner diagnosed moderate severe bilateral high frequency sensorineural hearing loss in the context of a history given by the veteran of noise exposure in service without noise exposure after service. Granting the veteran the full benefit of the doubt pursuant to 38 C.F.R. § 3.102, the Board finds that right ear hearing loss was incurred in service. c. Residuals of Agent Orange exposure claimed as lipomas and chloracne As noted above, the veteran's service administrative records show that he served two tours of duty in Vietnam. As a Vietnam veteran, the veteran is presumed to have been exposed to Agent Orange or other herbicide agents. 38 C.F.R. § 3.307. The evidence does not show that the veteran’s chloracne was manifest to a degree of 10 percent within one year of service, and lipomas are not included on the list of diseases under 38 C.F.R. § 3.309. As such, the provisions of 38 C.F.R. § 3.309(e) in regard to presumptive service connection are not for application in this case. However, as a VA physician has determined that the veteran currently has lipomas and chloracne, and that those conditions are secondary to Agent Orange exposure, the Board finds that a grant of service connection is in order pursuant to 38 C.F.R. § 3.303(d) as all the evidence establishes that the conditions were incurred as a result of service. d. Back disorder In this case, the veteran's service medical records are negative for complaints or diagnosis of any back disorder. The Board does accept the veteran's accounts that he jumped out of airplanes for 20 years, and that he had one instance in service of treatment for his back, even though the records are negative for any treatment, as the veteran has combat experience, 38 U.S.C.A. § 1154(b) § 38 C.F.R. § 3.304. The record also demonstrates that the veteran has a current back disability, degenerative arthritis. In order for a grant of service connection to be made, there must be competent medical evidence showing that a current disability is related to service. See Rabideau v. Derwinski 2 Vet.App. 141, 142-143 (1992). The connection between a current disability and service may also be made by a showing of a chronic disease in service, or of chronicity of symptomatology after service. As noted above, the veteran is afforded presumptions as to the insurance of disease or injury pursuant to 38 U.S.C.A. § 1154(b). Under § 1154(b), however, lay evidence may only be used to provide a factual basis upon which a determination could be made that a particular disease or injury was incurred or aggravated in service. § 1154(b) does not relieve the veteran of the burden of providing evidence of a nexus between a current injury and service. Gregory v. Brown, 8 Vet.App. 563 (1996). In this regard, the record contains no medical findings that the veteran's back disorder is related to service. In fact, the only such finding of record at all is the veteran's opinion that his back problems are due to jumping out of airplanes. A lay person such as the veteran may testify as to his symptoms, but is not competent to offer evidence that requires medical knowledge. Espiritu v. Derwinski, 2 Vet.App. 492, 494 (1992). As such, the Board places no weight on the veteran's opinions regarding causation of his back disorder. Further, the Board notes that service medical records show no evidence of a chronic back condition, as the veteran indicated on his retirement physical that he had no history of back problems. Additionally, the veteran has indicated that his back pain did not become chronic until 1980, over six years after his separation from service. Thus, the Board finds no evidence of continuity of symptomatology after service. The Board has also considered the veteran's argument that his back problems may be secondary to a right ankle disorder. However, the only relevant medical evidence is an opinion of a VA physician that there is no relationship between the ankle problem and the back disorder. In the absence of medical evidence that the veteran's current back disorder is related to service, or evidence of a chronic back disorder in service or the continuity of symptoms after service, the Board finds that a grant of service connection for a back disorder is not warranted, 38 C.F.R. §§ 1110, 1131, 1154; 38 C.F.R. § 3.303, 3.304. e. Residuals of Agent Orange exposure, claimed as breathing difficulties, upset stomach, dry hands, skin lesions, slow healing of wounds, and sexual dysfunction Section 5107 of Title 38, United States Code unequivocally places an initial burden upon the claimant to produce evidence that his claim is well grounded; that is, that his claim is plausible. See Grivois v. Brown, 6 Vet.App. 136, 139 (1994); see Grottveit v. Brown , 5 Vet.App. 91, 92 (1993). Because the veteran has failed to meet this burden, the Board finds that his claim for service connection for residuals of Agent Orange exposure, claimed as breathing difficulties, upset stomach, dry hands, skin lesions, slow healing of wounds, and sexual dysfunction is not well grounded and should be denied. Where the determinative issue involves a question of medical diagnosis or medical causation, competent medical evidence to the effect that the claim is plausible or possible is required. See Murphy v. Derwinski, 1 Vet.App. 78, 81 (1990). The claimant does not meet this burden by merely presenting his lay opinion because he is not a medical health professional and does not constitute competent medical authority. See Espiritu v. Derwinski, 2 Vet.App. 492 (1992). Consequently, his lay assertions cannot constitute cognizable evidence, and as cognizable evidence is necessary for a well grounded claim, see Tirpak v. Derwinski, 2 Vet.App. 609, 611 (1992), the absence of cognizable evidence renders a veteran's claim not well grounded. In order for a claim to be well grounded, there must be competent evidence of current disability (a 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, 506 (1995). In this regard, the Board notes that the record contains no medical evidence that the veteran currently suffers from respiratory problems, gastrointestinal problems, dry hands, or slow healing of wounds. While the record does indicate that the veteran had been treated for sexual dysfunction, the examiner attributed the disorder to a venous problem. Benign skin lesions and nevus lesions have also been diagnosed, but the examiner only said they were possibly related to Agent Orange exposure. A physician’s opinion that a particular condition may or may not have caused a secondary condition is “speculative,” and is insufficient to justify a belief by a fair and impartial individual that a claim is well-grounded. See Tirpak at 611. The Board notes further that neither sexual dysfunction nor benign skin lesions or nevus lesions are among the diseases granted presumptive service connection under 38 C.F.R. § 3.309(e). Therefore, that provision is not for application in this case. In the absence of competent medical evidence of record linking residuals of Agent Orange exposure, claimed as breathing difficulties, upset stomach, dry hands, skin lesions, slow healing of wounds, or sexual dysfunction to service, it appears that the veteran's claim is predicated on his own opinion. As it is the province of trained health care providers to enter conclusions which require medical opinions as to causation, see Grivois, the veteran's lay opinion is an insufficient basis to find this claim well grounded. See Espiritu. Accordingly, as a well grounded claim must be supported by competent medical evidence, not merely allegations, see Tirpak, the veteran's claim for service connection for residuals of Agent Orange exposure, claimed as breathing difficulties, upset stomach, dry hands, skin lesions, slow healing of wounds, and sexual dysfunction must be denied as not well grounded. In reaching this determination, the Board recognizes that this issue is being disposed of in a manner that differs from that used by the RO. The Board therefore considered whether the veteran has been given adequate notice to respond, and if not whether he has been prejudiced thereby. See Bernard v. Brown, 4 Vet.App. 384, 394 (1993). In light of the veteran’s failure to meet his initial burden in the adjudication process, the Board concludes that he has not been prejudiced by the decision to deny his appeal. In such a situation, the Board is not denying service connection on the merits, but rather is finding that the veteran has failed to meet his obligation of presenting a claim that is plausible, or capable of substantiation, at this time. If the veteran or his representative can secure competent medical evidence that residuals of Agent Orange exposure, claimed as breathing difficulties, upset stomach, dry hands, skin lesions, slow healing of wounds, and sexual dysfunction is linked to service, such evidence may be used in the filing of another claim. In reaching its decision, the Board notes that the Court has held that there was some duty to assist the veteran in the completion of his application for benefits under 38 U.S.C.A. § 5103(a) (West 1991 and Supp. 1996), depending on the particular facts in each case. Beausoleil v. Brown, 8 Vet.App. 459 (1996); Robinette v. Brown, 8 Vet.App. 69 (1995). The facts and circumstances of this case are such that no further action is warranted. ORDER Service connection is granted for hearing loss in the right ear, a foot condition diagnosed as chronic fungal dermatitis of the feet or onychomycosis, and residuals of exposure to Agent Orange claimed as chloracne and lipomas. Service connection for a back disorder is denied. The veteran not having submitted a well grounded claim for entitlement to service connection for residuals of Agent Orange exposure, claimed as breathing difficulties, upset stomach, dry hands, skin lesions, slow healing of wounds, and sexual dysfunction, the claim is denied. REMAND Service medical records indicate that the veteran was treated in service for two sprains of the right ankle. X-rays showed no fracture or dislocation. The veteran has indicated that he had chronic instability of the ankle, and underwent surgery in 1982. The records from that surgery are unavailable. During VA examination in August 1994, the veteran was diagnosed with synovitis and probable degenerative arthritis in the right ankle. The VA Schedule for Rating Disabilities, 38 C.F.R. Part 4 (1996), holds that it is an essential requirement that examinations view each disability in relation to its history, 38 C.F.R. § 4.1 (1996), that a diagnosis be supported by the findings on the examination, and that the report contain sufficient detail, 38 C.F.R. § 4.2 (1996). In this regard, the Board notes that during the August 1994 examination, it does not appear the veteran's service medical records were reviewed, and no opinion was offered as to the relationship between the veteran's in-service sprains and his current disability. The Board is of the opinion therefore, that a reexamination of the appellant would be of assistance in this case. Therefore, pursuant to VA’s duty to assist the appellant in the development of facts pertinent to his claim under 38 U.S.C.A. § 5107(a) (West 1991 & Supp. 1996); 38 C.F.R. § 3.103(a) (1996), the Board is deferring adjudication of the issue of entitlement to service connection for a right ankle disorder pending a remand of the case to the RO for further development as follows: 1. The RO should arrange for an examination of the appellant by an orthopedic surgeon in order to determine the nature and etiology of any disability found to be present in the right ankle. The claims file and a separate copy of this remand must be made available to and reviewed by the examiner prior to conduction and completion of the examination. The examiner should conduct any testing deemed necessary. The result of all testing should be fully reported. Any opinion(s) expressed must be accompanied by a complete rationale. In conjunction with a review of the veteran's claims file, it is requested that the examiner render an opinion as to the following: (a) What pathology is associated with the veteran's right ankle? (b) For each disability identified in (a), is it at least as likely as not that the disability is etiologically related to the ankle sprains suffered by the veteran in service? 2. Following completion of the foregoing development, the RO should review the requested examination and required opinion to ensure that they are responsive to and in complete compliance with the directives of this remand and if they are not, the RO should implement corrective procedures. 3. After undertaking any development deemed appropriate in addition to that specified above, the RO should readjudicate the issue of entitlement to service connection for a right ankle disorder. If the benefit sought on appeal is not granted to the veteran’s satisfaction, the RO should issue a supplemental statement of the case. A reasonable period of time for a response should be afforded. Thereafter, the case should be returned to the Board for final appellate review, if otherwise in order. By this remand, the Board intimates no opinion as to any final outcome warranted. No action is required of the veteran until he is notified by the RO. 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. 1996) (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. RONALD R. BOSCH Member, Board of Veterans’ Appeals 38 U.S.C.A. § 7102 (West Supp. 1996) permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991 & Supp. 1996), a decision of the Board of Veterans’ Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans’ Judicial Review Act, Pub. L. No. 100-687, § 402, 102 Stat. 4105, 4122 (1988). The date that appears on the face of this decision constitutes the date of mailing and the copy of this decision that you have received is your notice of the action taken on your appeal by the Board of Veterans’ Appeals. Appellate rights do not attach to those issues addressed in the remand portion of the Board’s decision, because a remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (1996). - 2 -