Citation Nr: 0814119 Decision Date: 04/29/08 Archive Date: 05/08/08 DOCKET NO. 99-03 672 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Indianapolis, Indiana THE ISSUE Entitlement to service connection for residuals of a brain injury. WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Carolyn Wiggins, Counsel INTRODUCTION The veteran served on active duty from November 1965 to October 1967. This appeal arises from a March 1998 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Indianapolis, Indiana. An August 2007 rating decision granted service connection for a lumbar spine disorder, a cervical disorder and a residuals of a right knee injury. The only issue which remains for appellate review is the issue of service connection for residuals of a brain injury. The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if further action is required. REMAND The veteran has described his residuals of a brain injury as headaches and emotional disturbance. Although noted previously, the claims folder does not contain current diagnoses of either a psychiatric disorder or headaches. The record does show that when examined for VA purposes in connection with this matter in December 1997, it was determined that a neurologist would have been a more appropriate examiner. A follow-up examination does not appear to have been undertaken until 2004, yet it is unclear if this was performed by a neurologist. As such, another examination should be scheduled. In addition, this examiner did not address whether a psychiatric disorder or chronic headache disorder was present, and related to service. This question was likewise not directly addressed in a January 2007 evaluation, although it was indirectly accomplished where the examiner noted there was no residual of an in- service head trauma. Nevertheless, an opinion that explicitly addresses whether there is a current psychiatric/head disability, and if so, its relationship to service would be useful. It is also noted the veteran submitted a release for VA to obtain his records of treatment from his psychiatrist, Dr. Kennedy. VA has requested those records and received no response. The only records of treatment from Dr. Kennedy in the claims folder were obtained when VA received the veteran's records from the Social Security Administration. By this remand the Board is notifying the veteran that if he wishes those records to be considered he must obtain and submit them himself. Accordingly, the case is REMANDED for the following actions: 1. VA should request the veteran to identify all health care providers who have treated him for headaches and a psychiatric disorder, prior to 1986 and after 1989. With any necessary authorization from the veteran, the VA should attempt to obtain copies of pertinent treatment records identified by the veteran. 2. VA should arrange of the veteran to be examined by a neurologist and psychiatrist. The claims folder should be made available to the examiners in conjunction with the examination. The examiners are asked to identify any current chronic headache and/or psychiatric disability found to be present, and for any such current disability identified, the examiner should offer an opinion as to whether it/they is/are related to service, or any incident therein. In this regard, the examiners should note the August 1964 Report of Medical History on which the veteran checked a history of depression or excessive worry; the July 1967 separation examination, the July 1967 Report of Medical History on which the veteran checked no as to a history of depression, loss of memory, nervous trouble and periods of unconsciousness; private medical records from 1986 through 1989 containing diagnoses of depression, somatoform disorder, anxiety and post traumatic pain, two photographs of the veteran revealing lacerations to the head and facial bruising; the December 1997 VA examination report indicating the veteran had headaches every day; and the June 2004 and January 2007 VA examination reports. The examiners also should comment on whether any current chronic headache or psychiatric disorder was caused or aggravated (increased in severity) by any currently service connected disability, (i.e., status post total right knee prosthesis with severe degenerative osteoarthritis; lumbosacral strain with degenerative disc disease; and cervical spine strain with degenerative changes). 3. Thereafter, the claim should be re- adjudicated. If the benefit sought on appeal remains denied the veteran should be provided with an appropriate supplemental statement of the case and be given opportunity to respond. The case should then be returned to the Board for further appellate review. The appellant has the right to submit additional evidence and argument on the matter 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. 2007). _________________________________________________ MICHAEL E. KILCOYNE Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. 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) (2007).