BVA9502932 DOCKET NO. 93-08 190 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Buffalo, New York THE ISSUE Entitlement to an increased (compensable) evaluation for the residuals of an excision of a cyst of the left shoulder. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD J.R. King, Associate Counsel REMAND The appellant served on active duty from July 1981 to July 1987. This matter is before the Board of Veterans Appeals (Board) on appeal from a September 1991 rating determination of the Department of Veterans Affairs (VA) Regional Office (RO) located in Buffalo, New York, which denied the appellant's claim for a compensable evaluation for the residuals of an excision of a cyst of the left shoulder. Service connection was granted and a noncompensable evaluation assigned in this case by rating determination in November 1989. The evidence which was of record at that time included the appellant's service medical records, reflecting that the appellant presented in March 1987 with complaints of two bumps on the left shoulder. Examination disclosed what were described as two small subcutaneous sebaceous cysts. In April 1987, the appellant underwent a surgical procedure to excise two cysts from his left shoulder. Microscopic analysis of the cysts revealed that they consisted of scar tissue. The appellant sought medical treatment in July 1989 at the VA Medical Center in Canandaigua, New York, for complaints of pain over the left shoulder. The examiner noted that the incision line of the previous surgery had enlarged, and another bump was present beside the scar. VA clinical records dated in August 1989 reflect that the appellant had a left shoulder keloid excised at the site of the scar from his previous operation. The appellant indicated to the examiner that the new growth started six moths after the previous surgery, that it continued to grow in size, and that it was painful. At the time the sutures were removed, the examiner stated that the surgical scar was well- healed. An August 1989 VA pathological report reflects that, on microscopic examination, the diagnosis was: keloid, left shoulder. A May 1991 statement from the appellant is of record, reflecting his contentions that he experiences pain in his left shoulder and tingling down his forearm into his fingers. He also stated that he experiences an aching sensation on the left side of his neck. The appellant indicated that he had been treated by a Dr. Harbhajan S. Birdee and that the RO should obtain records of this treatment. Pursuant to this statement the RO obtained a November 1988 Major Surgery Record from the Newark Wayne Community Hospital which reflects that the appellant sustained trauma from broken window glass to his left forearm resulting in a large laceration with bleeding. A 3 inch long laceration was noted, which had divided the flexor carpi ulnaris muscle. The examiner noted that the fascia was partly divided on top of this muscle and that the edges of the muscle were visible in the wound. The hand movements to the appellant's fingers were noted to be normal. A myorrhaphy of the flexor carpi ulnaris of the left forearm was performed by Dr. H.S. Birdee on that occasion. The appellant thereafter underwent an August 1991 VA examination in which he provided a narrative history of having been treated for carpal tunnel syndrome of the left wrist in January 1991 at the Newark Wayne Community Hospital by Dr. Knapp. Records of this treatment are not of record. Moreover, the appellant underwent a subsequent VA examination of the left upper extremity in March 1992, at which time neither the November 1988 nor the January 1991 clinical history of treatment appear to have been made apparent to the examiner. Inasmuch as the appellant has indicated that he lost 75-85 percent of his strength as a result of the VA surgical excision of the left shoulder cyst, it is necessary to obtain a clinical opinion as to the etiology of any neurological or musculoskeletal impairment of the appellant's left upper extremity. The United States Court of Veterans Appeals (Court) has held that the duty to assist may arise when the veteran simply refers to private medical examinations even when there is no specific request that the VA obtain these records. Caffrey v. Brown, 6 Vet.App. 377 (1994). Moreover, the fact that the appellant has asserted that his painful episodes of left shoulder and arm pain are so severe as to require that he seek medical treatment is sufficient to trigger the VA duty to assist him in the development of facts pertinent to his claim. The Court held in Caffrey that a veteran's claim that his condition has become more severe is well grounded where the condition was previously service connected and rated, and he subsequently asserts that a higher rating is justified. The Board is of the opinion that the appellant should be afforded a neurologic and orthopedic examination to determine the etiology and severity of any neurological or musculoskeletal impairment found. Given the jurisprudence of the Court, and the evidentiary development which is necessary in this claim, it is REMANDED for the following action: 1. The appellant should be requested to provide the names and approximate dates of treatment pertaining to any pathology of the left arm and shoulder. Copies of all clinical records not already of record from Drs. Knapp and Harbhajan S. Birdee and the Newark Wayne Community Hospital should be obtained for inclusion in the claims folder. The appellant should be provided with the appropriate release of information forms in order to obtain copies of these records. 2. The appellant should be afforded a VA orthopedic and neurological examination in order to determine the nature and etiology of any pathology of the left upper extremity and shoulder. The claims folder and a copy of this REMAND should be made available to the examiner(s) in conjunction with the examination. The examiner(s) should be requested to delineate, if possible, the symptomatology and pathology referable to his service-connected status post left shoulder cyst excision (keloid) versus that resulting from the November 1988 laceration of the left forearm and the January 1991 left wrist carpal tunnel syndrome. 3. The claim should then be reviewed by the RO. If the disposition remains adverse to the appellant, he and his representative should be provided with a Supplemental Statement of the Case and an opportunity to respond. Thereafter, the case should be returned to the Board, if in order. The Board intimates no opinion as to the ultimate outcome of this case. The appellant need take no action unless otherwise notified. J.F. GOUGH Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), 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. Under 38 U.S.C.A. § 7252 (West 1991), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Veterans Appeals. This 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) (1993).