Citation Nr: 1000102 Decision Date: 01/04/10 Archive Date: 01/14/10 DOCKET NO. 08-00 099 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Portland, Oregon THE ISSUES 1. Entitlement to service connection for chronic upper thoracic pain with myofascial trigger points in the parathoracic muscles at levels T4-T6 (chronic upper thoracic pain). 2. Entitlement to service connection for chronic bronchitis and asthma, claimed as a respiratory condition. 3. Entitlement to service connection for a bilateral knee condition. 4. Entitlement to service connection for a right wrist condition, including as secondary to service-connected chronic cysts. 5. Entitlement to service connection for bilateral hearing loss. 6. Entitlement to service connection for stuttering. 7. Entitlement to an initial disability rating greater than 30 percent for a forehead scar. 8. Entitlement to an initial compensable rating for chronic cysts. 9. Entitlement to an initial disability rating greater than 10 percent for residuals of pneumothorax. 10. Entitlement to an effective date earlier than February 23, 2006 for a grant of service connection for pneumothorax residuals, migraines, and chronic cysts. REPRESENTATION Veteran represented by: Oregon Department of Veterans' Affairs ATTORNEY FOR THE BOARD Helena M. Walker, Associate Counsel INTRODUCTION The Veteran had active service from September 1991 to January 1999. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Portland, Oregon. The issues of entitlement to service connection for chronic thoracic pain, bronchitis, asthma, right wrist disability, and for stuttering, and entitlement to higher initial ratings for a forehead scar and for chronic cysts are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the Veteran if further action is required on his part. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the Veteran's appeal has been obtained. 2. The Veteran currently is not shown to have a bilateral knee disability attributable to active service. 3. The Veteran currently is not shown to have bilateral hearing loss attributable to active service. 4. The Veteran's pulmonary function tests revealed, at worst, FEV-1/FVC of 70 percent pre-bronchodilator and 72 percent post-bronchodilator. 5. The Veteran filed his claim for service connection for migraines, chronic cysts, and pneumothorax residuals on February 23, 2006. There is no prior informal claim of service connection for these disabilities. CONCLUSIONS OF LAW 1. A bilateral knee disability was not incurred in active service. 38 U.S.C.A. §§ 1111, 1112, 1113, 1131, 1137, 1153 (West 2002); 38 C.F.R. §§ 3.303, 3.306, 3.307, 3.309, 3.310(a) (2009). 2. Bilateral hearing loss was not incurred in active service. 38 U.S.C.A. §§ 1101, 1111, 1112 (West 2002); 38 C.F.R. §§ 3.303, 3.306, 3.307, 3.309, 3.385 (2009). 3. The criteria for an initial rating greater than 10 percent for residuals of pneumothorax have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1-4.14, 4.97, Diagnostic Code (DC) 6843 (2009). 4. The criteria for assignment of an effective date earlier than February 23. 2006, for the grant of service connection for migraines, chronic cysts, and pneumothorax residuals have not been met. 38 U.S.C.A. § 5110 (West 2002); 38 C.F.R. §§ 3.400, 3.155 (2009). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Before assessing the merits of the appeal, VA's duties under the Veterans Claims Assistance Act of 2000 (VCAA) must be examined. The VCAA provides that VA shall apprise a Veteran of the evidence necessary to substantiate his claims for benefits and that VA shall make reasonable efforts to assist a Veteran in obtaining evidence unless no reasonable possibility exists that such assistance will aid in substantiating the claim. In letters dated in March 2006 and March 2009, VA notified the Veteran of the information and evidence needed to substantiate and complete his claims for service connection including what part of that evidence he was to provide and what part VA would attempt to obtain for him. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The letters also generally advised the Veteran to submit any additional information in support of his claims. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). Additional notice of the five elements of a service-connection claim, as is now required by Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), was provided in March 2009. Although the Board acknowledges that the Veteran was not provided VCAA notice regarding his increased rating and earlier effective date claims, he is not prejudiced by the instant decision. The Court has indicated that, in a claim for a higher initial evaluation, after the claim for service connection has been substantiated and allowed, as in this case, further notice is not required. See Goodwin v. Peake, 22 Vet. App. 128 (2008). Additionally, the Veteran was provided notice of disability ratings and effective dates in March 2009 pursuant to Dingess. Finally, the Veteran has been represented by a Veterans' Service Organization in this appeal, and neither the Veteran nor his service representative has asserted defective VCAA notice and any prejudice therefrom. As such, the Board finds that VA met its duty to notify the Veteran of his rights and responsibilities under the VCAA. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (discussing the rule of prejudicial error). With respect to the timing of the notice, the Board points out that the United States Court of Appeals for Veterans Claims (Court) held in Pelegrini that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim for VA benefits. In this case, the initial March 2006 VCAA notice was issued prior to the currently appealed rating decision dated in September 2006. Under these circumstances, the Board finds that the notification requirements of the VCAA have been satisfied as to both timing and content. The Board also finds that VA has complied with the VCAA's duty to assist by aiding the Veteran in obtaining evidence, affording him physical examinations, obtaining medical opinions as to the etiology and severity of his disabilities, and by affording him the opportunity to give testimony before the RO and the Board, although he declined to do so. VA is not required to schedule the Veteran for a physical examination for his bilateral knee and bilateral hearing loss claims because the evidence does not meet the criteria set forth in 38 C.F.R. § 3.159(c)(4). Specifically, there is no credible evidence of an event, injury, or disease in service upon which a current disability may be based. In fact, the Veteran has no current diagnosis of a bilateral knee condition or bilateral hearing loss. As such, the Board finds that remand is not required with respect to these claims. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (holding that remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the claimant are to be avoided). It appears that all known and available records relevant to the issues here on appeal have been obtained and are associated with the Veteran's claims file. Thus, the Board finds that VA has done everything reasonably possible to notify and assist the Veteran and that no further action is necessary to meet the requirements of the VCAA. Service connection The Veteran seeks service connection for a right knee condition, a left knee condition, and bilateral hearing loss. Service connection for VA compensation purposes will be granted for a disability resulting from disease or personal injury incurred in the line of duty or for aggravation of a preexisting injury in the active military, naval or air service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). 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). There must be competent evidence showing the following: (1) the existence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and a disease or injury incurred or aggravated during service. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Hickson v. West, 12 Vet. App. 247 (1999). Arthritis and sensorineural hearing loss are considered chronic diseases under 38 C.F.R. § 3.309(a). As such, service connection may be granted if the evidence shows that the diseases manifest to a degree of ten percent or more within one year from the date of separation from service. 38 C.F.R. § 3.307. Knee conditions The Veteran seeks service connection for a bilateral knee condition. The Veteran's service treatment records (STRs) reflect treatment for complaints of right knee pain first in September 1991 and again in October 1991. Following the 1991 treatment and for the duration of the Veteran's active duty, he did not have any complaints of any additional right knee pain. Further, there was no diagnosis of a right knee disability noted at the time of service separation. The STRs reflect no treatment for a left knee disability. The Veteran waived his discharge medical examination, but there are no service treatment records evidencing any chronic bilateral knee disability. The Veteran's post-service treatment records are devoid of any complaints or findings related to his bilateral knees. There is simply no clinical evidence of record noting any treatment for a current bilateral knee condition. The Board finds that the preponderance of the evidence is against the Veteran's claim of service connection for a bilateral knee condition. There is no current diagnosis of a bilateral knee condition which could be attributed to active service. Absent a disease or injury incurred during service or as a consequence of a service-connected disability, the basic compensation statutes cannot be satisfied. See Sanchez-Benitez v. Principi, 259 F.3d 1356, 1361 (Fed. Cir. 2001). Also, in the absence of proof of a present disability, there can be no valid claim. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The Board recognizes that there was an acute instance of treatment for complaints of right knee pain in 1991. There was no subsequent treatment for, or a finding of, a chronic right knee disability, however. Absent evidence of a bilateral knee condition related to the Veteran's service or a finding of arthritis of the knees within one year of service separation, the Board finds that service connection for a bilateral knee condition must be denied on both a direct and presumptive service connection basis. Bilateral hearing loss The Veteran seeks service connection for bilateral hearing loss. For the purposes of applying the laws administered by VA, impaired hearing will be construed 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, 3000 or 4000 Hertz are 26 decibels or greater; or, when speech recognition scores using the Maryland CNC Test are less than 94 percent. See 38 C.F.R. § 3.385. During service, the Veteran underwent three audiograms and in the most severe of the three, puretone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 05 05 00 05 10 LEFT 10 00 05 10 20 No speech discrimination scores were taken during this January 1992 audiogram. The Veteran's hearing loss profile was assessed as being H1. It was also noted that the Veteran was routinely exposed to hazardous noise. In a September 1996 audiogram, the Veteran's puretone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 05 05 05 05 LEFT 15 05 05 05 05 Again, no speech discrimination testing was performed, nor was there a separation medical examination that assessed hearing acuity. The evidence of record is devoid of any post-service treatment for, or diagnoses of, any hearing-related problems. The Board finds that the preponderance of the evidence is against the Veteran's claim of service connection for bilateral hearing loss. The threshold for normal hearing is from 0 to 20 decibels, and higher threshold levels indicate some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). There is no evidence of record to show any degree of hearing loss. Moreover, the findings at the Veteran's audiology examinations do not meet the requirement of a hearing loss disability as defined by VA regulations. 38 C.F.R. § 3.385. Absent competent medical evidence reflecting a hearing loss disability linked to the Veteran's service, the Board finds that service connection for bilateral hearing loss must be denied on a direct service connection basis. Further, as there is no evidence of record that the Veteran experienced bilateral hearing loss within a year of discharge from service, the Board finds that service connection also must be denied on a presumptive service connection basis. Increased ratings The Veteran contends that his service-connected residuals of pneumothorax are more severely disabling than currently evaluated. Disability evaluations are determined by the application of the schedule of ratings which is based on average impairment of earning capacity. See 38 U.S.C.A. § 1155. Separate diagnostic codes identify the various disabilities. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of a Veteran's disability. See Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. See Francisco v. Brown, 7 Vet. App. 55 (1994). Where entitlement to compensation has been established and a higher initial disability rating is at issue, the level of disability at the time entitlement arose is of primary concern. See Fenderson v. West, 12 Vet. App. 119 (1999). In Hart v. Mansfield, 21 Vet. App. 505 (2007), however, the Court held that "staged" ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Pneumothorax residuals The Veteran seeks an initial rating in excess of 10 percent for service-connected pneumothorax residuals. The Veteran's pneumothorax residuals currently are rated as 10 percent disabling under 38 C.F.R. § 4.97, DC 6843. The General Rating Formula for Restrictive Lung Disease (DC's 6840 through 6845) provides for a 100 percent evaluation for findings that show Forced Expiratory Volume (FEV-1) less than 40 percent of predicted value, or; the ratio of Forced Expiratory Volume in one second to Forced Vital Capacity (FEV-1/FVC) less than 40 percent, or; Diffusion Capacity of the Lung for Carbon Monoxide by the Single Breath Method (DLCO (SB)) less than 40-percent predicted, or; maximum exercise capacity less than 15 ml/kg/min oxygen consumption (with cardiac or respiratory limitation), or; cor pulmonale (right heart failure), or; right ventricular hypertrophy, or; pulmonary hypertension (shown by Echo or cardiac catheterization), or; episode(s) of acute respiratory failure, or; requires outpatient oxygen therapy. A 60 percent evaluation is assigned for FEV-1 of 40- to 55- percent predicted, or; FEV-1/FVC of 40 to 55 percent, or; DLCO (SB) of 40- to 55-percent predicted, or; maximum oxygen consumption of 15 to 20 ml/kg/min (with cardiorespiratory limit). A 30 percent evaluation is assigned for FEV-1 of 56- to 70- percent predicted, or; FEV-1/FVC of 56 to 70 percent, or; DLCO (SB) 56- to 65-percent predicted. A 10 percent evaluation is assigned for FEV-1 of 71- to 80- percent predicted, or; FEV-1/FVC of 71 to 80 percent or; DLCO (SB) 66- to 80-percent predicted. 38 C.F.R. § 4.97, DC's 6840-6845. Post-bronchodilator studies are required when pulmonary function testing (PFT) are conducted for disability evaluation purposes, except when the results of pre- bronchodilator PFTs are normal or when the examiner determines that post-bronchodilator studies should not be done and states the reasons why. 38 C.F.R. § 4.96. At a June 2006 PFT, the Veteran's FEV-1/FVC was 73 percent pre-bronchodilator and 72 percent post-bronchodilator. His FEV-1 was 103 percent predicted and his DLCO (SB) was 116 percent predicted. He was assessed as having a minimally obstructive airway defect. He underwent a VA examination that same month and reported continued chest pain and difficulty breathing. As such, he was awarded a 10 percent rating under the general rating formula for respiratory disorders. In his October 2008 VA examination, the Veteran again reported difficulty breathing and chest pain. The examiner indicated that any pulmonary function abnormality was likely the result of his 20-pack year history of smoking. His respiratory capacity was found to only be limited by pain and not by airflow as is measured at the PFT testing level. PFTs revealed FEV-1 at 108 percent, FEV1/FVC at 70 percent pre- bronchodilator and 72 percent post-bronchodilator, and DLCO (SB) at 106 percent. The Board finds that the preponderance of the evidence is against the Veteran's claim for an initial disability rating greater than 10 percent for residuals of pneumothorax. A 10 percent rating is the maximum rating for the residuals of his pneumothorax based upon this Veteran's symptomatology. At worst, the Veteran's FEV-1/FVC is 72 percent post- bronchodilator. There is no evidence that his FEV-1 is 56 to 70 percent predicted, that his FEV-1/FVC is 56 to 70 percent, or that his DLCO (SB) is 56 to 65 percent predicted. As such, the Veteran is not entitled to a higher initial rating for his service-connected pneumothorax residuals. The Board also has considered whether to assign staged ratings pursuant to Hart but finds that, under the circumstances of this case, staged ratings are not appropriate. Extraschedular The Veteran does not assert that he is totally unemployable because of his service-connected pneumothorax residuals alone. Nor has he identified any specific factors which may be considered to be exceptional or unusual in light of VA's schedule of ratings. Specifically, the Veteran has not required frequent periods of hospitalization for treatment of this service-connected disability. Loss of industrial capacity is the principal factor in assigning schedular disability ratings. See 38 C.F.R. §§ 3.321(a) and 4.1. 38 C.F.R. § 4.1 states, "Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." See also Moyer v. Derwinski, 2 Vet. App. 289, 293 (1992) and Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (noting that the disability rating itself is recognition that industrial capabilities are impaired). Because there is no evidence of the Veteran requiring frequent periods of hospitalizations due to his pneumothorax residuals, the Board finds that the evaluations currently assigned adequately reflects the clinically established impairment experienced by the Veteran. In the absence of requisite factors, the criteria for submission for assignment of an extraschedular rating for this disability pursuant to 38 C.F.R. § 3.321(b)(1) are not satisfied. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Consequently, the Board will not refer this claim to the Director of Compensation and Pension for extraschedular review. Earlier effective date The Veteran seeks an effective date of December 2005 for the grants of service connection for pneumothorax residuals, migraines, and chronic cysts. He contends that he submitted an informal claim for benefits via fax on December 27, 2005. In his notice of disagreement, he indicated that he attached a copy of this fax receipt. It appears as though is no fax receipt was attached to the notice of disagreement nor has one been associated with the Veteran's claims file. There is no other record received prior to February 23, 2006, that could be interpreted as an informal claim for benefits. Except as otherwise provided, the effective date of an evaluation and award of pension, compensation, or dependency and indemnity compensation based on an original claim, a claim reopened after final disallowance, or a claim for increase will be the date of receipt of the claim or the date entitlement arose, whichever is the later. See 38 C.F.R. § 3.400. The applicable statutory and regulatory provisions require that the VA look to all communications from the appellant which may be interpreted as applications or claims-formal and informal-for benefits. In particular, the VA is required to identify and act on informal claims for benefits. 38 U.S.C.A. § 5110(b)(3); 38 C.F.R. §§ 3.1(p), 3.155(a); see Servello v. Derwinski, 3 Vet. App. 196, 198-200 (1992). Any communication or action, indicating an intent to apply for one or more benefits under the laws administered by the VA, from a claimant, his or her duly authorized representative, a Member of Congress, or some person acting as next friend of a claimant who is not sui juris may be considered an informal claim. Such informal claim must identify the benefit sought. Upon receipt of an informal claim, if a formal claim has not been filed, an application form will be forwarded to the claimant for execution. If received within one year from the date it was sent to the claimant, it will be considered filed as of the date of receipt of the informal claim. 38 C.F.R. § 3.155. The Board finds that the preponderance of the evidence is against the Veteran's claim for an effective date earlier than February 23, 2006, for the grants of service connection for migraines, chronic cysts, and pneumothorax residuals. Following a complete review of the record, there is no evidence of an informal claim of service connection for migraines, chronic cysts and pneumothorax residuals having been filed prior to February 23, 2006. See Brannon v. West, 12 Vet. App. 32, 35 (1998) (concluding that the Board must "review the claim, supporting documents, and oral testimony in a liberal manner to identify and adjudicate all reasonably raised claim"). There is no evidence of some other submission from the Veteran prior to February 23, 2006 that identified a sought benefit of service connection for these disabilities. See MacPhee v. Nicholson, 459 F.3d 1323, 1326- 27 (Fed. Cir. 2006) (holding that plain language of regulations require claimant to have intent to file claim for VA benefits). The Board acknowledges the Veteran's assertions that he submitted an informal claim in December 2005 but there is no documentation of this claim in the claims file to support his contentions. ORDER Entitlement to service connection for a bilateral knee condition is denied. Entitlement to service connection for bilateral hearing loss is denied. Entitlement to an initial disability rating greater than 10 percent for pneumothorax residuals is denied. Entitlement to an effective date earlier than February 23, 2006, for the grants of service connection for migraines, chronic cysts, and pneumothorax residuals is denied. REMAND Upon review of the record, and in light of the VCAA, the Board finds that further evidentiary development is necessary regarding the claims of service connection for chronic thoracic pain, bronchitis and asthma, right wrist disability, and the increased rating claims for chronic cysts and forehead scar. Service connection Chronic thoracic pain, asthma, bronchitis The Veteran has a history of pneumothorax and he is service connected for its residuals. STRs reflect multiple complaints of back and chest pain. In December 1992, the Veteran had a motor vehicle accident and experienced a mild cervical strain. There was no indication whether this impacted the thoracic spine. A September 1995 STR indicated that the Veteran complained of headaches and neck pain secondary to an automobile accident. He reported a dull pain between his scapula. A March 1997 STR notes the Veteran's reported history of experiencing whiplash three times prior and the physician indicated that his complaints were consistent with whiplash. There is also a June 1998 STR reflecting the Veteran's complaints of right-sided pain near the location of where the chest tube had been placed. The Veteran complained of sharp shooting pain that goes from his chest and feels like a knot in his back. The STRs, however, are devoid of any finding of chronic bronchitis or asthma. In an August 2003 private treatment record, the Veteran was diagnosed as having bronchitis and mild asthma. There was no finding made as to the etiology of the claimed bronchitis and asthma. In the Veteran's June 2006 VA examination, he was diagnosed as having chronic upper thoracic pain with myofascial trigger points in the parathoracic muscles at levels T4-T6. The examiner, however, was unable to determine the origin of this problem in relationship to the Veteran's history of pneumothorax or trauma without resort to speculation. In the more general VA examination performed that same month, the Veteran was noted to have pleuritic-type pain in the posterior right thorax that is exacerbated by any increased breathing or coughing. He advised that he was told he had a degree of bronchospasm and/or an asthmatic condition. The Veteran was also found to have a pleural adhesion at the site of his chest tube placement. The examiner diagnosed the Veteran as having dyspnea on exertion, etiology unclear. The examiner further noted that the Veteran had a "significant amount of trauma" when the chest tube was inserted during service, but he indicated that there was "currently no evidence of physiologic complication from that event or procedure." In the Veteran's October 2008 VA examination, the Veteran reported continued pleuritic pain in the posterior right thorax that is seriously exacerbated by coughing or deep breathing. The examiner indicated that the significant impact of his in-service treatment for pneumothorax was pleuritic pain due to scarring from the chest tube. The examiner also indicated that any pulmonary function abnormality is likely the result of his 20-pack year history of smoking. The Veteran reported experiencing three to four respiratory infections per winter. Although the Veteran underwent two VA examinations, the Board finds that another VA examination is necessary to address whether the Veteran's thoracic pain, bronchitis, and asthma were caused or aggravated by his service-connected pneumothorax residuals. Also, there is some confusion as to whether the Veteran's chest-tube placement residuals were in any way related to his claimed thoracic pain. Indeed the Veteran has diagnoses of thoracic pain, bronchitis and asthma, but there is no conclusive opinion regarding whether these were caused or aggravated by his service-connected pneumothorax. The October 2008 VA examiner indicated that the Veteran's chest pain was likely a valid disorder "often a residual problem after chest tube placement," but he did not indicate whether this was the same as the diagnosed chronic upper thoracic pain with myofascial trigger points in the parathoracic muscles at levels T4-T6. The examiner also opined that it is at least as likely as not that the Veteran experiences recurrent pleuritic pain in the posterior thorax with deep breathing and coughing; however, he did not indicate whether this is attributable to his history of pneumothorax. He also did not indicate whether the Veteran's history of pneumothorax aggravated the claimed thoracic pain, bronchitis, and asthma. As such, the Board finds that another VA examination should be scheduled to determine whether the Veteran's history of pneumothorax caused or aggravated the claimed chronic thoracic pain, bronchitis, and/or asthma. Stuttering The Veteran contends that his preexisting stuttering worsened during service. He only seeks service connection on an aggravation basis and has not contended that his stuttering was caused by service. He underwent speech pathology sessions during service and was diagnosed as having moderate stuttering. His enlistment medical examination made no reference to a preexisting stuttering condition, but the Veteran reported its onset as being at 2 years of age in a July 1995 treatment record. The Veteran contends that he currently experiencing a stuttering condition, and he is certainly competent to report those symptoms. No VA examination, however, has addressed this issue. The Veteran indeed sought treatment for his stuttering during service. Upon careful examination of the medical evidence of record, the Board finds that a remand is also necessary for a VA examination to be scheduled regarding his claims of entitlement to service connection for a stuttering disorder. There is some evidence that the Veteran may have had a pre- service stuttering disorder that was not noted upon enlistment. Additionally, there is evidence that the Veteran was treated for stuttering during service, and it was noted in his STRs that the Veteran reported having a stuttering disorder prior to service. Thus, it is not entirely clear whether the Veteran had a stuttering disorder that existed prior to his service. If the Veteran did not have a stuttering disorder that existed prior to his service, it is not clear whether the currently diagnosed stuttering disorder is related to the symptomatology and treatment shown in his STRs. Increased rating for chronic cysts and forehead scar, and service connection for a right wrist condition The Veteran seeks a rating in excess of 30 percent for his service-connected forehead scar and an initial compensable rating for his chronic cysts. The Board notes that the Veteran's forehead scar is attributable to his service- connected chronic cysts and was separately rated in a December 2008 rating decision. He was also awarded a 10 percent rating for his thigh scar due to cyst removal in December 2006. There is also evidence that the Veteran had other scarring caused by cysts-such as the scars from a right wrist ganglion cyst as noted above. More recently, the Veteran was noted to have a cyst in his chin area and has a history of cysts around the ears. The Veteran also seeks service connection for a right wrist condition that he attributes to his in-service ganglionectomy of the right dorsum wrist. STRs also reflect a May 1992 treatment for a complaint of right wrist pain. The Veteran reported no pre-service trauma to the right wrist. He was assessed as having a right wrist sprain. As noted above, he was later treated for a right wrist ganglion cyst during service. There are no post- service treatment records reflecting complaints of a right wrist disability. During his June 2006 VA examination, the Veteran's right wrist ganglion cyst removal was noted. The examiner diagnosed the Veteran as having status-post ganglion removal of the right wrist, "without consequence." Following review of the Veteran's claims file, the examiner indicated that his ganglion cyst on the right wrist was unlikely related to the Veteran's dermal inclusion cysts such as the one removed from his right thigh. In an addendum, the Veteran's right wrist cyst residuals were noted to include a 2.5 cm X 1 mm pinkish scar vertically across the proximal aspect of the right index finger metacarpal. The scar was noted to be slightly tender and was depressed 1.5 mm. There was no ulceration or adherence of the scar and it was found to be minimally disfiguring. The Veteran was noted to have sharp pain within the tissue under the scar when the wrist is extended and dull pain in that area when the wrist is flexed. The Board finds that in regards to the Veteran's service- connected chronic cysts and his request for service connection for a right wrist disability, another VA examination would be helpful to properly rate this Veteran and determine whether he is entitled to service connection for a separate right wrist disability. As noted above, the Veteran separately seeks service connection for a right wrist disability, but the Board notes that this could be the same disease process as his already service-connected chronic cysts. Morever, the VA examinations regarding the skin disabilities do not indicate the Veteran's total number of scars due to his service-connected chronic cysts and the percentage of coverage on the Veteran's body (both exposed and unexposed surfaces). Further, a VA examination is required for the Veteran's claim of service connection for a right wrist disability to determine whether it is of the same process as the cysts for which he is currently service connected. The Board is aware that the June 2006 VA examiner did not attribute his right ganglion cyst removal to the cyst removal on his right thigh, but no opinion was given as to whether it was related to other cysts associated with his service-connected chronic cysts-such as his forehead cyst. Moreover, there is clearly evidence that the Veteran has a scar on the right wrist and there is a history of a ganglion cyst removal, but there is no opinion as to whether any right wrist disability is attributable to his in-service treatment for a ganglion cyst in that area. As such, a VA examination should be scheduled to determine the nature, severity and etiology of his chronic cysts and right wrist disability. The examination should also include an opinion as to whether the Veteran's right wrist disability is directly related to service or to a service-connected disability. Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a VA examination to determine the nature and etiology of any lung disorder and/or thoracic disability related to his service-connected pneumothorax residuals. The claims file must be provided for review. The examiner should offer an opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that any currently diagnosed lung disorder and thoracic disability originated during the Veteran's active service. The examiner also should provide an opinion as to whether any current chronic thoracic pain, bronchitis, and asthma were aggravated by service- connected pneumothorax residuals. A complete rational should be provided for any opinions. If the requested opinion cannot be provided without resort to speculation, the examiner should so state and explain why such an opinion cannot be provided. 2. Schedule the Veteran for a VA examination to determine the nature and etiology of any stuttering disorder that may be present. The claims file must be provided for review. The examiner is asked to review all pertinent records associated with the claims file, particularly the Veteran's service treatment records, and offer comments, clarification, and an opinion as to the following questions: (i) Does the evidence of record clearly and unmistakably show that the Veteran had a stuttering disorder that existed prior to his entry to service? Please explain what evidence supports you conclusion. (a) If a stuttering disorder did exist prior to entry to service, did it increase in severity during service? (b) If the stuttering disorder increased in severity during service, did the increase in severity represent a chronic worsening of the disorder or was the increase in severity the natural progression of the disorder? (ii) If the examiner determines that a stuttering disorder did not exist prior to service, is any currently diagnosed stuttering disorder causally or etiologically related to the symptomatology shown in service treatment records? 3. Schedule the Veteran for a VA examination to determine the current severity of his chronic cysts and forehead scar and to determine whether his claimed right wrist condition is attributable to his service-connected chronic cysts or directly attributable to service. The claims file must be provided for review. Appropriate testing should be performed to identify any associated objective symptoms of the claimed disabilities. The examiner should render an opinion as to whether the Veteran's claimed right wrist disability is at least as likely as not (i.e., a 50 percent or greater probability) related to his in-service ganglion cyst removal on the right wrist. Then the examiner should assess whether any right wrist disability was caused by the same disease process as the Veteran's service-connected chronic cysts. The examiner should note the current severity of the Veteran's chronic cysts and forehead scar disabilities, including the number, location, and sizes of the scars related to his chronic cysts. 4. Thereafter, readjudicate the claims on appeal. If the benefits sought are not granted, the Veteran and his representative should be furnished a Supplemental Statement of the Case, and be afforded a reasonable opportunity to respond before the record is returned to the Board for further review. The purpose of this REMAND is to cure an evidentiary defect and the Board does not intimate any opinion as to the merits of the case, either favorable or unfavorable, at this time. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. 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 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2009). ______________________________________________ MICHAEL T. OSBORNE Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs