Citation Nr: 1341109 Decision Date: 12/12/13 Archive Date: 12/20/13 DOCKET NO. 09-36 266 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUE Entitlement to service connection for residuals of traumatic brain injury. REPRESENTATION The Veteran is represented by: Illinois Department of Veterans Affairs ATTORNEY FOR THE BOARD S. Pflugner, Counsel INTRODUCTION The Veteran served on active duty from November 2002 to March 2003 and from November 2004 to February 2006. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office in Chicago, Illinois (RO). This case was remanded by the Board in May 2012, March 2013, and July 2013, for additional development. Subsequent to the completion of this development, the claim has been remitted to the Board for further appellate review. FINDING OF FACT The evidence of record does not demonstrate the current presence of residuals of traumatic brain injury, or that residuals of traumatic brain injury were present at any point during the pendency of the appeal. CONCLUSION OF LAW Residuals of traumatic brain injury were not incurred in or due to active military service. 38 U.S.C.A. §§ 1110, 5103A, 5107 (West 2002); 38 C.F.R. § 3.303 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION VA has a duty to notify and assist veterans in substantiating claims for VA benefits. 38 U.S.C.A. §§ 5102, 5103, 5103A (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.156(a), 3.159, 3.326(a) (2013). Proper notice from VA must inform the veteran of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the veteran is expected to provide. Quartuccio v. Principi, 16 Vet. App. 183 (2002). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). The notice requirements apply to all five elements of a service connection claim, including: (1) veteran status; (2) existence of a disability; (3) a connection between the appellant's service and the disability; (4) degree of disability; and (5) effective date of the disability. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); see also Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. Prior to the March 2008 rating decision, the RO's August 2007 letter advised the Veteran of the elements of the notice requirements. Specifically, the August 2007 letter provided notice to the Veteran of the requisite evidence to establish the claim; the evidence VA would provide; the evidence the Veteran was expected to submit; and the elements of service connection, in addition to notice that a disability rating and an effective date for the award of benefits will be assigned if service connection was awarded. See Quartuccio, 16 Vet. App. at 187; Dingess/Hartman, 19 Vet. App. at 486. The purpose behind the notice requirement has been satisfied because the Veteran has been afforded a meaningful opportunity to participate effectively in the processing of his claim, including the opportunity to present pertinent evidence. Thus, the Board finds that the content requirements of the notice VA is required to provide have been met. See Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004). In addition, the duty to assist the Veteran has been satisfied in this case. The RO obtained the Veteran's service treatment records and his identified VA and private treatment records. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. There is no indication in the record that additional evidence relevant to the issues being decided herein is available and not part of the record. See Pelegrini, 18 Vet. App. at 120. The Veteran was provided VA examinations in November 2007 and November 2012 in order to ascertain the presence of residuals of traumatic brain injury and, if any present, whether they are related to his active duty or an event occurring therein. The examiners reviewed the Veteran's relevant records, considered the Veteran's statements, and performed thorough clinical examinations. The examiners also provided comprehensive rationales for the opinions reached. As such, the Board finds that the November 2007 and November 2012 VA examinations are adequate for purposes adjudicating the Veteran's claim. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). As noted above, the Board remanded this matter in May 2012, March 2013, and July 2013. In the May 2012 remand, the Board directed the RO to (1) obtain and associate with the record the Veteran's VA treatment records dated in and after March 2012; (2) obtain and associate with the record the Veteran's treatment records from the Community Memorial Hospital; and (3) afford the Veteran a VA examination to determine the nature, extent, onset, and etiology of any residuals of a traumatic brain injury. Thereafter, the RO was directed to readjudicate the Veteran's claim and, if the benefit sought on appeal was denied, issue a supplemental statement of the case. After he had an adequate opportunity to respond, the RO was to remit the Veteran's claim to the Board for further appellate review. While the Veteran's claim was in remand status, the RO requested, obtained, and associated with the record the Veteran's treatment reports from the Community Memorial Hospital. The Veteran was then provided an adequate VA examination in November 2012. The RO readjudicated the Veteran's claim, confirming and continuing the denial thereof. The RO then issued the Veteran a December 2012 supplemental statement of the case, wherein the RO indicated that the Veteran's VA treatment records, dated from March 2012 to March 2013, were reviewed. The RO then remitted the Veteran's claim to the Board. In the March 2013 remand, the Board observed that, although the RO indicated that the Veteran's VA treatment records, dated from March 2012 to March 2013, were considered in the readjudication of his claim, records dating from December 2012 to March 2013 were not associated with the record. As such, the Board remanded the Veteran's claim in order to ensure compliance with the May 2012 remand directives. The Board directed the RO to associate the Veteran's VA treatment records. While the claim was in remand status, the RO again requested the Veteran's VA treatment reports from March 2012 to March 2013. The RO then readjudicated the claim, continuing and confirming the denial thereof, and then issued a May 2013 supplemental statement of the case. In the July 2013 remand, the Board again noted that VA treatment records dated from December 2012 to March 2013 were not associated with the Veteran's electronic or paper claims file. The Board again directed that such treatment reports be added to the record. The RO readjudicated the claim, and continued the denial in a September 2013 supplemental statement of the case. Therein, the RO effectively determined that its previous indication that the evidence of record included the Veteran's VA treatment records dated from December 2012 to March 2013 was an error. The RO indicated that the Veteran's most recent VA treatment report was dated on December 3, 2012. After the Veteran had a reasonable opportunity to respond, the claim was remitted to the Board for further appellate review. Based on the above, the Board finds that the RO substantially complied with the remand directives and, thus, a remand for corrective action is not warranted. See Stegall v. West, 11 Vet. App. 268, 271 (1998). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of these matters, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); Shinseki v. Sanders, 129 S. Ct. 1696 (2009)(reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination) (2009). Service connection may be granted on a direct-incurrence basis for a disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110; 38 C.F.R. § 3.303. Service connection may also be granted for any disease initially diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease was incurred during service. 38 U.S.C.A. § 1113(b) (West 2002); 38 C.F.R. § 3.303(d); Cosman v. Principi, 3 Vet. App. 503, 505 (1992). In order to establish direct service connection for a disorder, there must be (1) competent evidence of the current existence of the disability for which service connection is being claimed; (2) competent evidence of a disease contracted, an injury suffered, or an event witnessed or experienced in active service; and (3) competent evidence of a nexus or connection between the disease, injury, or event in service and the current disability. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); see Hickson v. West, 12 Vet. App. 247, 253 (1999); see also Pond v. West, 12 Vet App. 341, 346 (1999). The salient issue presented by the Veteran's above-captioned service connection claim is whether the evidence of record establishes a current diagnosis of residuals of traumatic brain injury. See Degmetich v. Brown, 104 F.3d 1328, 1333 (1997) (holding that the existence of a current disability is the cornerstone of a claim for VA disability compensation); see also McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (holding that the requirement that there be a current disability is satisfied when the disability is shown at the time of the claim or during the pendency of the claim, even though the disability subsequently resolves). As such, the Board will focus its analysis on this issue. The Veteran claims that he sustained traumatic brain injuries during his active duty and that he is currently experiencing residual disability due to those injuries. Specifically, the Veteran has asserted that he sustained a traumatic brain injury in November or December 2004 as a result of an incident with a Humvee, claiming that the Humvee ran over him and he sustained a head injury. The Veteran also asserted that he was exposed to two blasts from improvised explosive devices (IED), one occurring in June 2005, and the other occurring in October 2005. A November 2004 Department of Defense pre-deployment health assessment demonstrated that the Veteran's health was considered "very good," and that referral for evaluation was not warranted with respect to any specific medical specialty. Ultimately, he was deemed "deployable." According to December 2004 emergency services records, the Veteran was "hit by a vehicle." When emergency services arrived, he was conscious and oriented, but complained of neck and right ankle pain. December 2004 treatment reports from Community Medical Center demonstrated that the Veteran sought treatment for injuries sustained as a result of an incident involving a Humvee. The Veteran stated that his right ankle was run over by the vehicle and that the vehicle hit his head, twisting his neck and upper back. He denied loss of consciousness and severe headache, but endorsed neck, thoracic spine, and right ankle pain. Radiological examination of his cervical spine, thoracic spine, and right ankle was negative for fracture. Ultimately, it was determined that there was no evidence of a serious head injury or neurologic injury. Contemporaneous active duty treatment records pertained only to the Veteran's right ankle injury. A June 2005 service treatment record indicated that the Veteran struck his right wrist against a gun turret; there was no mention of an IED blast or a head injury. A December 2005 Department of Defense post-deployment health assessment showed that the Veteran reported that his health stayed about the same or got better during his deployment. He then denied experiencing various symptoms, including headaches and difficulty remembering. The examining health care provider deemed the Veteran's health to be "very good," and that referral for further evaluation was not warranted with respect to any specific medical specialty. According to a January 2006 Department of Defense post-deployment health assessment, the Veteran indicated that his health stayed about the same or got better. He denied experiencing headaches and difficulty remembering. The examiner indicated that the Veteran's health was considered "very good," and, based on his report of inservice events and symptoms, that referral for an audiological assessment was appropriate; the Veteran was not recommended for referral for combat/operational stress reaction or neurological evaluations. A December 2006 VA psychiatric initial consultation report demonstrated that the Veteran complained of sleeping difficulties due to being an "active thinker." He discussed dreams, nightmares, and night sweats. With respect to this childhood, the Veteran stated that his parents thought he had attention deficit disorder (ADD) or attention deficit hyperactivity disorder (ADHD) because he experienced difficulties with concentration, acting out, and being the class clown. After reviewing his relevant history, include reference to participation in combat and being in Iraq from January 2005 to January 2006, the "possible" diagnoses were Adult ADD, predominately inattentive type as Adult, and posttraumatic stress disorder (PTSD). In February 2007, the Veteran underwent a VA neuropsychology consultation due to his concerns about experiencing ADD. Specifically, the Veteran endorsed a difficulty concentrating and learning in school. During the consultation, he stated that he experienced sports-related concussions in high school that rendered him unconscious for "seconds." After clinical testing, the examiner provided the following as part a summary: Based on the profile of neuropsychological data this patient shows a pattern of scores that show some areas of cognitive difficulty. The configuration of scores does not suggest an attention deficit disorder per se; however, the test scores do suggest the presence of difficulties in attention and processing speed. These difficulties may be related to an early injury as he describes in his history. He denied any recent head injuries and the pattern of scores does not suggest recent injury. Several days later, the Veteran appeared for a follow-up appointment to discuss the results of the ADD testing. After discussing the test results and the Veteran's response to treatment since the previous appointment, the diagnoses were Adult ADD, predominately inattentive type as Adult, and PTSD, with sleeping issues related to ADD or PTSD. Also in February 2007, the Veteran underwent a VA psychiatry consultation concerning possible PTSD and ADHD. The Veteran stated that he experienced ADHD-type behavior in his childhood, but was never tested. He endorsed difficulty concentrating, disturbing memories, nightmares, flashbacks, avoidance of discussing events, and difficulty sleeping. During the consultation, the Veteran indicated that he was deployed in 2004. Further, during an assessment to see if his symptoms meet the diagnostic criteria for PTSD, the Veteran reported that his most memorable event was being hit by something unknown (represented in the report as a series of questions marks) and taking fire. However, with respect to a past medical history significant for loss of consciousness, the Veteran endorsed sports-related incidents wherein he "took a big hit." After reviewing the Veteran's medical history and treatment, and after administering a clinical evaluation, the diagnoses were ADHD, predominately inattentive type versus learning disorder, not otherwise specified, and PTSD. An April 2007 VA psychiatric follow-up note demonstrated that the Veteran's chief complaint was ADHD. The examiner indicated that the Veteran was last seen on February 22, 2007, which was the initial psychiatric consultation. At that time, the Veteran "seemed" to meet the diagnostic criteria for PTSD, although the severity appeared to have diminished through counseling. The examiner also indicated that neuropsychiatric testing supported a diagnosis of ADHD. After reviewing the Veteran symptoms and response to treatment since the previous appointment, and after administering additional clinical testing, the impression was ADHD, predominately inattentive type versus learning disorder, not otherwise specified, and PTSD. A June 2007 report of medical history demonstrated that the Veteran denied then or ever experiencing dizziness or fainting spells; frequent or severe headache; and head injury, memory loss, or amnesia. According to an October 2007 VA Polytrauma Support Clinic Team Return note, the Veteran appeared for evaluation of head injury following an attack with an IED with loss of consciousness. The Veteran denied prior episode of brain injury, but endorsed previous a concussion. As a result of the IED attack, the Veteran endorsed experiencing a headache. He stated that he was currently being treated for PTSD, but denied Major Depression and anxiety. He reported the following symptoms: dizziness; poor coordination/clumsy; vision problems/blurry vision; sensitivity to noise; change in sense of taste/smell; headaches; sensitivity to light; numbness/tingling; forgetfulness; slowed thinking; poor concentration; difficulty making decisions; fatigue; and irritability. After a physical examination, the assessment was as follows: No significant clinical evidence of traumatic brain injury[,] but a mild traumatic brain injury would be difficult to exclude. No evidence of decline in functional performance due to current symptoms. According to a November 2007 addendum to October 2007 VA treatment report, the Veteran specified that he had close exposure to two IED explosions. As a result of one of the explosions, he stated that he experienced a brief loss of consciousness, while as a result of the other he experienced a change in mental status. The Veteran also stated that a vehicle rolled over his head, but that he did not sustain a significant injury because the terrain was very sandy and his head was pushed into the sand. He claimed that he underwent neuroimaging following this incident, but that the work-up was negative. He endorsed persistent problems with memory, working memory, attention, and naming. Additionally, he indicated that he had been diagnosed with ADHD as a child. In November 2007, the Veteran underwent a VA examination to ascertain the presence of residuals of a traumatic brain injury and, if present, whether the found residuals were etiologically associated with his military service, specifically exposure to IED explosions and/or other head injuries. Preliminarily, the examiner review the Veteran's service treatment records, including his November 2006 post-deployment assessment, which was negative for neurological symptoms. The Veteran stated that the date of onset for his symptoms was November 2004, June 2005, and October 2005. With respect to the November 2004 incident, the Veteran claimed that a Humvee ran over his head, neck, and leg during a training exercise; he denied loss of consciousness. He described his post-injury symptoms as "normal post-concussion symptoms," such as feeling dazed and confused and having a headache for about one week, which resolved in about one week without further problems. Prior to this injury, the Veteran reported no history of concussions or head injuries. With respect to the June 2005 incident, the Veteran stated that he was serving as a convoy gunner in Baghdad when an IED exploded next to his vehicle. He endorsed loss of consciousness for less than 10 seconds, and feeling dazed and confused and experiencing really bad headaches. Additionally, the Veteran endorsed losing his sense of smell. He stated that he saw a medic, but was sent back to duty. The Veteran reported that his headaches never went away after this blast, and that he was irritable. The examiner then indicated that the Veteran endorsed being exposed to another IED explosion, "concussion wave," and a loss of consciousness for 30 seconds. He stated that he experienced the same symptoms after, including headaches and loss of sense of smell. The Veteran then endorsed problems with concentration. After extensive clinical testing, the "diagnosis" was "alleged [traumatic brain injury]" without further elaboration. In December 2007, the Veteran underwent a VA psychiatric examination in order to ascertain the presence of PTSD and, if so, whether it was incurred in or due to the Veteran's military service. During this examination, the Veteran reported experiencing closed head injuries secondary to IED blasts while serving in Iraq. Ultimately, after reviewing his relevant histories and administering clinical testing, the examiner rendered a diagnosis of cognitive disorder, not otherwise specified. The examiner then stated that the Veteran's symptoms of PTSD included hypervigilance and nightmares, but he did not meet all of the diagnostic criteria. The examiner suggested that the Veteran's irritability "could" be from his brain injury or from PTSD symptoms. The examiner included an Axis III diagnosis of traumatic brain injury related to 2 separate IED blasts. Additionally, the examiner continued as follows: [The Veteran] has a brain injury from 2 IED explosions and related attention, memory, difficulties, irritability which was documented in [a] Feb[ruary] 2007 neuropsych[iatric] evaluation. Second to his Traumatic exposures he has had bad dreams and some mild hypervigilance. Continue to follow at risk for mood difficulties related to stress of attending college (with a brain injury) time, working part-time, and parenting 2 pre-school children. Moreover, the examiner then stated that the Veteran had symptoms "consistent with" a traumatic brain injury (inattention, memory loss, irritability), and had symptoms of PTSD. According to a December 2007 VA treatment report, the Veteran appeared for a follow-up appointment concerning his ADHD and PTSD. After reviewing the Veteran's recent treatment reports, including the two 2007 VA examination reports, the examiner administered additional testing. Ultimately, the impression was ADHD, predominately inattentive type versus learning disorder, not otherwise specified, and PTSD. This impression was echoed by a VA social worker in a treatment report dated the same day. A January 2008 VA neuropsychiatric note demonstrated that the "preliminary findings" were that the Veteran experienced an organic mood syndrome secondary to a traumatic brain injury, a cognitive disorder secondary to a traumatic brain injury, and probably PTSD due to combat, although his PTSD may be somewhat obscured by the effects of his organic mood syndrome and cognitive disorder. In a February 2008 addendum to the December 2007 VA psychiatric examination, the examiner opined that it was "more likely than not" that the Veteran had PTSD. The examiner then stated that it "appears," based on the findings from the January 2008 VA neuropsychiatric note, that the Veteran's PTSD symptoms are "likely" obscured by his organic and cognitive disorder which was due to traumatic brain injury. According to a March 2008 addendum to the January 2008 neuropsychiatric note, the examiner interviewed the Veteran with respect to his symptoms. The Veteran reported a variety of symptoms, including memory trouble, lack of focus, difficulties with concentration, decreased sense of smell, and ringing in his ears. He stated that an IED blast rammed his head into a gun turret. He claimed that exposure to a second IED blast rendered him dazed for about one week. After clinical testing, the impression was symptoms consistent with the "possibility" of an organic mood syndrome secondary to blast concussion exposure, with moderate attentional dysfunction that "may" reflect "possible" pre-morbid ADHD that was also consistent with blast concussion exposure and "possible" ADHD by history that was not believed to be the Veteran's major cognitive problem. The examiner continued by stating that the Veteran's condition "might" also be referred to as a subtype of organic mood syndrome, or, alternatively a psychiatric disorder secondary to a general medical condition, namely traumatic brain injury. In November 2012, the Veteran underwent another VA examination to ascertain the presence of residuals of a traumatic brain injury and, if any present, whether they were incurred in or due to his military service. The Veteran underwent a contemporaneous computed tomography scan, the relevant result of which will be included the examiner's rationale below. The examiner indicated that the Veteran had experienced mild, repeated traumatic brain injury, without current evidence of residuals. The examiner identified the Veteran's traumatic brain injuries as occurring in high school in the mid 1990s and in June 2005. The Veteran detailed the event surrounding the June 2005 IED explosion, the symptoms he experienced as a result, and the treatment he received. Upon clinical testing, the examiner observed objective evidence of mild impairment of memory, attention, concentration, or executive functions resulting in mild functional impairment. Further, the Veteran's judgment was deemed normal; his social interaction was routinely appropriate; he was always oriented to person, time, place, and situation; he exhibited normal motor activity; his visual spatial orientation was normal, as was his neurobehavioral effects; and he was able to communicate by spoken and written language and to comprehend spoken and written language. Further, his consciousness was normal. With respect to subjective symptoms, the examiner indicated that the Veteran endorsed symptoms that did not interfere with work, instrumental activities of daily living, or occupational, familial, or other close relationships. The examiner then indicated that the Veteran did not have any subjective symptoms or any mental, physical, or neurological conditions or residuals attributable to a traumatic brain injury. The Veteran was then provided additional VA examinations pertaining to headaches, loss of sense of smell or taste, and PTSD. Ultimately, the examiner opined that the Veteran's claimed residuals of traumatic brain injury were "less likely than not (less than 50 percent probability) incurred in or caused by the claim in-service injury, event, or illness." In support of this conclusion, the examiner provided the following rationale: After review of the Veteran's records including but not limited to the [claims] file and service treatment/medical records, recent medical examinations, diagnostic testing, consultations as well as interviewing the Veteran about his medical [and] psychiatric history, current symptoms, the Veteran was examined (medical and psychiatrically) and current pertinent medical literature was reviewed. Based on all this information and clinical experience, it is my medical opinion that the Veteran's claimed traumatic brain injury and/or any residuals of traumatic brain injury is much less likely as not (much less than 50/50 probability) caused by or a result of a specific illness, injury or event [including but not limited to the 2004 Humvee training accident with foot injury and/or IED/blast exposure] that occurred during the Veteran's military service. While this Veteran was seen [December 8, 2004] at Community Memorial Hospital, there is no indication of any significant head or brain injury of any kind. Examination shortly after the Humvee apparently ran over his right foot with a report that he was also hit [in] his head, there were no physical exam[ination] findings on the scalp, head or on neurological testing at the time of Emergency Department evaluation immediately after the accident nor were any apparent or reported on follow-up examination...Today, the [V]eteran does not report the 2004 Humvee accident but does report a [June 2005] brief loss of consciousness in Baghdad with exposure to a blast. He reports being medically evaluated later that same day, although no military medical care records for the treatment or evaluation of head injury [were] found. There are also no medical records of subsequent complaints for any other symptoms suggestive of [traumatic brain injury] or common [traumatic brain injury] residuals during the remainder of military service. In additional to the lack of records for [traumatic brain injury] evaluation or care, there are also multiple self-report forms both immediately after deployment and later post-deployment questionnaires...where the [V]eteran specifically and consistently denied any head injuries, surrogate signs or symptoms of head injuries or their residuals. This [V]eteran was asked directly today about any incidents other than the [June 2005] IED (including any other motor vehicle accidents or injuries from animals, falls, sports or other events, in the service or outside of the service) when he hit his head, regardless of whether he thought he had a concussion, this [V]eteran denied any such events but also did not report the 2004 Humvee incident. However, this [V]eteran has reported in the past...periods of loss of consciousness in high school due to sports. Today, when asked directly about this discrepancy, the [V]eteran denied loss of consciousness prior to military service but reported episodes of 'seeing stars' and being dazed after taking hard hits during school sports events. All [of] this information, in conjunction with clinical experience leads to the conclusion that although this [V]eteran was apparent[ly] exposed to a blast at the Baghdad airport in 2004, it is very unlikely that there was any associated loss of consciousness. It is possible that in the setting of life-threatening danger, that the self-described emotional impact of that alone might be sufficient to make accurate recollection of events difficult despite the apparent clear recall of event, lack of amnestic period and apparent confidence in the information provided. Finally, this [V]eteran underwent a brain [computed tomography scan]; apparently for the first time, and was found to have a small area of hypodensity in the central mid-brain. Findings like this can be the result of trauma, congenital blood vessel malformation or due to uncontrolled elevated blood pressure (hypertension). The traumatic events described by the [V]eteran and evidence in his medical records would not be likely (much less likely as not) result in this type of abnormality particularly without requiring immediate medical attention or attention shortly after the trauma. The [V]eteran does have a diagnosis of hypertension which was more problematic when taking stimulants for ADD, although he is young. Finally, none of the traumatic brain injuries were of sufficient severity as described, to result in the residual symptoms reported by this [V]eteran today. In addition, the delay in onset of residuals by days to years is not consistent with the etiology of those conditions being the head injuries. The alterations in sense of smell is typical for sinus and nasal allergies and past/current cigarette smoking but is extremely unlikely from head injury in which shearing forces typically result in unilateral or bilateral anosmia being at the time of the injury and remaining unchanged over time. As demonstrated above, the evidence of record included several opinions as to the presence of residuals of traumatic brain injury. The Board must weigh the above evidence and decide where to give credit and where to withhold the same and, in so doing, accept certain medical opinions over others. Schoolman v. West, 12 Vet. App. 307, 310-11 (1999). The Board is also mindful that it cannot make its own independent medical determination, and that there must be plausible reasons for favoring one medical opinion over another. Evans v. West, 12 Vet. App. 22, 31 (1998). The Board may favor the opinion of one competent medical expert over that of another provided the reasons for that determination are stated. Winsett v. West, 11 Vet. App. 420, 424-25 (1998). The evidence of record included four opinions that were favorable to the Veteran's claim as to whether residuals of traumatic brain injury are present. First, the October 2007 VA medical professional ultimately opined that a mild traumatic brain injury would be difficult to exclude, but did not actually render a diagnosis of residuals of a mild traumatic brain injury. Moreover, it did not appear as though additional clinical testing was ordered in order to confirm this diagnosis. Indeed, the medical professional indicated that there was "no significant clinical evidence of traumatic brain injury." As such, the Board finds that the October 2007 opinion is inconclusive and too speculative to be probative in this matter. Obert v. Brown, 5 Vet. App. 30, 33 (1993) (medical opinions that are speculative, general, or inconclusive in nature cannot support a claim). Second, as a result of a December 2007 VA examination concerning psychiatric disabilities, namely PTSD, the examiner provided an Axis III diagnosis of traumatic brain injury related to 2 separate IED blasts. There was no indication in the resulting examination report that the examiner considered the Veteran's pertinent service treatment records in determining that the Veteran had been exposed to inservice IED blasts. Further, there was no indication that the examiner reviewed the service treatment records concerning the Veteran's symptomatology subsequent to the alleged exposure to IED blasts. Significantly, the examiner did not discuss the Veteran's June 2007 denial of then or ever experiencing dizziness or fainting spells; frequent or severe headache; and head injury, memory loss, or amnesia. Moreover, the examiner did not consider whether the Veteran's inservice treatment history (or lack thereof) fit the disability picture associated with traumatic brain injuries due to IED blasts or whether a delay in the onset of the Veteran's now claimed symptoms was possible. As such, the Board finds that the December 2007 VA examiner's opinion is not probative with respect to the matter at issue herein as it failed to consider all of the relevant evidence of record and did not provide an adequate rationale. See Reonal v. Brown, 5 Vet. App. 458, 460-61 (1993) (holding that medical opinions based on incomplete or inaccurate factual premise are not probative); Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Third, the January 2008 VA doctor provided "preliminary findings" that the Veteran experienced an organic mood syndrome and a cognitive disorder secondary to a traumatic brain injury. Given that these were self-described by the doctor as "preliminary findings," the opinion is inconclusive and too speculative to be probative in this matter. Id. Further, no rationale was provided to support the conclusions reached and, thus, the Board cannot ascertain whether doctor applied valid medical analysis to the significant facts of the particular case in order to reach the conclusions provided. Thus, the January 2008 opinion is not probative. Nieves-Rodriguez, 22 Vet. App. at 304. Finally, in a March 2008 addendum to the January 2008 preliminary findings, the doctor provided a detailed discussion of the Veteran's condition, including clinical findings. However, the doctor ultimately opined that the Veteran's symptoms were consistent with the "possibility" of an organic mood syndrome secondary to blast concussion exposure. A medical opinion expressed in terms of "possible" is too speculative to establish the presence of a current disability. Obert, 5 Vet. App. at 33. Further, the doctor then equivocates by stating that the Veteran's condition "might" also be referred to as a subtype of organic mood syndrome, or, alternatively a psychiatric disability. This opinion does not provide a definitive diagnosis of residuals of traumatic brain injury and, instead, suggests several possibilities as to the nature of the Veteran's disability. Consequently, the Board finds that the March 2008 opinion lacks probative value. Id.; see also Warren v. Brown, 6 Vet. App. 4, 6 (1993) (holding that a doctor's statement framed in terms such as "could have been" is not probative). The remaining evidence of record did not include a diagnosis of residuals of traumatic brain injury, provided diagnoses other than residuals of traumatic brain injury (such as, but not limited to, ADD, ADHD, and PTSD), or specifically determined that residuals of traumatic brain injury were not present. The Board finds that the November 2012 VA examiner's opinion to be the most probative evidence of record. The examiner considered all of the Veteran's service treatment reports, administered a thorough clinical examination, and provided a detailed opinion, including a discussion as to the medical treatment the Veteran would have required had his exposure to inservice IED blasts resulted in the hypodensity revealed via imaging studies. Further, the examiner explained that the symptoms complained of by the Veteran did not correlate to the severity of the inservice IED blast(s) to which he was exposed. As such, the Board is persuaded by the November 2012 VA examiner's opinion. Schoolman, 12 Vet. App. at 310-11; Evans, 12 Vet. App. at 31; Winsett, 11 Vet. App. at 424-25. Further, in this, and in other cases, the Board may not base a decision on its own unsubstantiated medical conclusions. Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). Based on the above, the only competent and probative opinions of record were negative to the Veteran's claim as to whether residuals of traumatic brain injury are present or were present at any point during the pendency of this appeal. To the extent that the Veteran claims the current presence of residuals of a traumatic brain injury, or that residuals of a traumatic brain injury were present at some point during the pendency of this appeal, the Board finds that the matter of the determination of the presence of a disability is more suited to the realm of medical, rather than lay expertise, as such questions are too complex for a layperson to proffer a competent opinion. Although the evidence record indicated that the Veteran was in school to become a Nurse, the evidence of record does not demonstrate that the Veteran possesses the ability, knowledge, or experience to provide competent diagnostic opinions as to the presence of residuals of traumatic brain injuries. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Consequently, the Veteran's assertions do not constitute competent evidence as to the presence of residuals of a traumatic brain. Congress has specifically limited entitlement to service-connected benefits to cases where there is a current disability. "In the absence of proof of a present disability, there can be no valid claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Absent adequate medical evidence reflecting the current presence of the claimed disability, or that the disability was present at some point during the pendency of this appeal, a basis upon which to establish service connection for residuals of a traumatic brain injury has not been presented and the appeal must be denied. As the preponderance of the evidence is against finding a current diagnosis of residuals of a traumatic brain injury, the benefit-of-the-doubt rule does not apply. Accordingly, service connection for residuals of a traumatic brain injury is not warranted. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). ORDER Service connection for residuals of a traumatic brain injury is denied. ____________________________________________ U. R. POWELL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs