Citation Nr: 18148560 Decision Date: 11/08/18 Archive Date: 11/07/18 DOCKET NO. 07-07 977 DATE: November 8, 2018 REMANDED Entitlement to service connection for a stomach disability is remanded. Entitlement to service connection for a traumatic brain injury (TBI) is remanded. Entitlement to service connection for headaches is remanded. Entitlement to service connection for nerve damage, right wrist is remanded. Entitlement to service connection for chronic anxiety reaction with psychological gastrointestinal complaints is remanded. REASONS FOR REMAND In addition to the issues enumerated above, in October 2017, the Board also remanded the issue of entitlement to service connection for scoliosis of the spine. The RO issued a September 2018 rating decision in which it granted service connection for scoliosis of the lumbar spine with degenerative disc disease and degenerative joint disease. The RO also granted service connection for sciatic nerve lumbar radiculopathy of the bilateral lower extremities, and femoral nerve lumbar radiculopathy of the bilateral lower extremities. This constitutes a full grant of the claim and it is no longer before the Board. Entitlement to service connection for a stomach disability, a TBI, headaches, nerve damage (right wrist), and chronic anxiety reaction with psychological gastrointestinal complaints are remanded. The Board regrets the additional delay that accompanies a remand. However, in this case, a remand was specifically requested by the Veteran in his October 2018 Brief. The Board notes that the Veteran has undergone several VA examinations already. However, these examinations were focused largely on whether his stomach disability, nerve damage, chronic anxiety, and headaches were residuals of a TBI. The examinations were either inconclusive or inadequate. Most importantly, they did not address whether any of these symptoms were related to service notwithstanding their relationship to a TBI. The United States Court of Appeals for Veterans Claims (Court), in vacating the Board’s October 2013 Decision, gave instructions to adjudicate each issue separately. A December 2011 VA examiner stated that the Veteran had a TBI in 1966. There is no documentation of such an injury either in 1966 or anywhere else in the service treatment records or post service treatment records. The examiner reasoned that all of the Veteran’s memory symptoms, loss of concentration, and headaches began after the injury and that the Veteran still has residuals of memory dysfunction and headaches. The examiner did not have the claims file available for review. She submitted a September 2012 addendum opinion in which she stated that her opinion was unchanged even after examining the claims file. The Veteran also underwent a VA examination in May 2013. The examiner opined that the Veteran sustained a TBI during service and that his residuals were at least as likely as not incurred in or caused by the claimed in-service injury. Her rationale was that headaches and decreased concentration began after the head injury with TBI, and that he had no difficulty with these symptoms prior to the TBI. However, when asked for a more thorough rationale in July 2013, she appeared to change her mind in stating that it was less likely than not that the Veteran’s current headaches were incurred in or caused by his in-service headaches or TBI. The Veteran underwent a CT scan in August 2013. The scan revealed mild, age related changes of the brain. Otherwise, it was negative. The May 2013 VA examiner noted that the CT brain scan did not substantiate a TBI in service, but neither did it negate the possibility that a TBI occurred during service. Therefore, even with the benefit of diagnostic testing, she could not say whether the Veteran sustained a TBI in service without resorting to speculation. Consequently, the previous examinations have not adequately answered the question of whether the Veteran sustained a TBI during service. Moreover, they did not address whether these symptoms (headaches, stomach disability, nerve damage, and chronic anxiety) are related to service (notwithstanding a diagnosis of a TBI). The service treatment records reflect that the Veteran was treated for a sore wrist in October 1962, pain in his abdomen (epigastrium region) in April 1964, an irritable colon in August 1964, and an irritated stomach from April 1965 to June 1965. On his July 1966 Report of Medical History, the Veteran handwrote that he had persisting stomach trouble since April 1964, including chronic pain in his abdomen near epigastrium region. He indicated, by checked box, that he had frequent indigestion, stomach, liver, or intestinal trouble, reaction to serum, drug, or medicine, and car, train, sea, or air sickness. Consequently, the Veteran reported symptoms during service. The Board finds that a VA examination is warranted to determine the nature and etiology of the Veteran’s disabilities. Specifically, the examiner should address whether such disorders may be directly related to service, separate from any claimed TBI. Additionally, the Board notes that the Court found that in adjudicating the Veteran’s claims, the VA should consider the Veteran’s testimony that as a corpsman in the infirmary, he was able to receive informal, and often undocumented treatment during service. The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination or examinations by an appropriate clinician(s) to determine the nature and etiology of any TBI, stomach disability, headaches, wrist disability (nerve damage), and a psychiatric disability. The examiner must opine: (a) whether it is at least as likely as not that the Veteran sustained a TBI or other head injury during service, (b) If yes, whether it is at least as likely as not that any stomach disability, headaches, wrist disability (nerve damage), and a psychiatric disability are related to that TBI, (c) whether it is at least as likely as not that the Veteran’s stomach disability began during service or was caused by service, to include the pain in his abdomen (epigastrium region) noted in April 1964, the irritable colon noted in August 1964, and/or the irritated stomach documented from April 1965 to June 1965, (d) whether it is at least as likely as not that the Veteran’s headaches began during service or was caused by service, to include headaches reported in March 1966, (e) whether it is at least as likely as not that the Veteran’s right wrist disability (nerve damage) began during service or was caused by service, to include the sore wrist for which he sought treatment in October 1962, and (f) whether it is at least as likely as not that the Veteran’s psychiatric disability/anxiety began during service or was caused by service. The examiner(s) must acknowledge that, as a corpsman in the infirmary, the Veteran was able to receive informal, and often undocumented treatment during service. Therefore, a negative nexus opinion should not be solely based on the lack of documentation during service ERIC S. LEBOFF Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. Prem, Counsel