Citation Nr: 18151022 Decision Date: 11/16/18 Archive Date: 11/16/18 DOCKET NO. 15-01 096 DATE: November 16, 2018 REMANDED Entitlement to service connection for scars of the head is remanded. Entitlement to service connection for residuals of head trauma is remanded. Entitlement to service connection for an acquired psychiatric disability is remanded. REASONS FOR REMAND 1. Entitlement to service connection for scars of the head 2. Entitlement to service connection for residuals of head trauma The Veteran contends that he currently has a traumatic brain injury, which he sustained in service after falling off a mountain while attempting a climb. The Board acknowledges that the Veteran’s service treatment records are mostly unavailable for review. An October 2011 memorandum reflects a formal finding of unavailability of service treatment records, after outlining all efforts made to obtain them. Thus, there is no documentation of the Veteran’s reported in-service injury to the head. In fact, the Board notes that VA has conducted additional development in an effort to verify the Veteran’s statement regarding an in-service injury involving falling down a mountain. The Joint Service Record Research Center (JSRRC) made a formal finding that the Veteran’s statement regarding his in-service injury is not corroborated. The basis for this finding was that review of the Veteran’s personnel file does not document the incident, nor do the admittedly incomplete service treatment records. Review of the Veteran’s post-service medical records shows that in August 1991, radiology report of the Veteran’s skull revealed no evidence of fracture or other bone abnormality, unremarkable paranasal sinuses, and normal facial bones. VA treatment records reflect that the Veteran first complained of headaches in May 2011. In June 2011, the Veteran was administered a CT scan of the head to assess the etiology of his chronic headaches. No acute pathology was found, though some fluid was shown in the frontal sinuses. The Veteran was prescribed allergy medication. In an August 2011 VA treatment note, the Veteran reported feeling his headaches are stress-related. In April 2012, the Veteran presented to the VA emergency department with headache complaints. The Veteran reported his headaches have been longstanding since a concussive injury in service. A neurological examination was shown to be intact. In May 2012, the Veteran was noted to take Citalopram, an SSRI, for treatment of his headaches. In May 2014, the Veteran was afforded a VA examination to assess of his claimed psychiatric disability. At that time, the Veteran was diagnosed with major depressive disorder. The examiner acknowledged the Veteran’s report of his fall in service. The Veteran reported having lost his footing and falling about 30 feet, incurring a head injury, and waking up in a Korean hospital after being unconscious. Pertinently, the examiner found that the Veteran does not have a diagnosis of traumatic brain injury. In July 2016, the Veteran had a hearing before a decision review officer. The Veteran testified that in August 1976, he and two military buddies were climbing a mountain in Korea to look down at a village, when he lost his footing and fell, landed on a rock, was knocked unconscious, and woke up in a hospital. The Veteran testified remembering waking up with his head bandaged up, his shoulder in a sling, being prescribed some medications, and being placed back in duty two weeks after the incident. The Veteran testified his behavior changed as a result. He could not recall any incident report being written by military authorities, explaining that he was unconscious and would not have known. The Board notes that while there is no evidence of a traumatic brain injury diagnosis, the Veteran does have a current diagnosis of chronic headaches, which he states he has had since the reported in-service fall ice. Further, the Veteran states that he currently has a scar on his head as a result of his in-service fall, and is claiming service connection for said scar. The Veteran, as a lay person, is not competent to testify as to the etiology of his claimed disabilities. See Barr v. Nicholson, 21 Vet. App. 303, 307 (2007) (holding that “lay persons are not competent to opine on medical etiology or render medical opinions.”). However, the Veteran is competent to testify as to symptoms which are capable of lay observation. See Charles v. Principi, 16 Vet. App. 370 (2002). The Veteran is thus competent to testify as to a fall in service, and to such symptoms as chronic headaches since service and a visible scar on his head. Finally, the Board notes that the Veteran was not afforded a VA examination to examine the nature and etiology of his claimed residuals of a head injury and associated scar. Given the Veteran’s competent testimony as to his symptoms and the unavailability of service treatment records, the Board finds that VA has a duty to provide the Veteran with an examination to evaluate the nature and etiology of his claimed conditions. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). Remand is required to schedule the Veteran for VA examination. 3. Entitlement to service connection for an acquired psychiatric disability is remanded. In May 2014, the Veteran was afforded a VA examination to assess the nature and etiology of his claimed psychiatric disability. The Veteran was diagnosed with major depressive disorder, polysubstance abuse disorder in remission, and unaddressed personality traits. The Board further notes that the examiner acknowledged the Veteran’s report of his fall in service as a valid stressor. However, the Board notes that this VA examination does not contain an etiological opinion with a supporting rationale. Furthermore, the examiner did not address an in-service stressor which was in fact verified by the JSRRC. Specifically, in addition to his fall, the Veteran also claimed exposure to a traumatic event involving two of his fellow soldiers being killed in an axe attack while he was stationed at Camp Casey in Korea. See January 2014 statement in support of claim. An April 2014 JSRRC memorandum concluded that it is plausible the Veteran knew the soldier that was killed as described in his statement – and pertinently found that the Veteran’s stressor is confirmed. As such, the Board finds that the Veteran’s May 2014 VA psychiatric examination is inadequate. 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). Further, to be adequate, an examination must provide a well-reasoned opinion supported with evidence of record. See Stefl v. Nicholson, 21 Vet. App. 120 (2007). In this case, no such opinion was provided. As the aforementioned VA examination is not adequate to adjudicate the issue, this claim must be remanded for a new VA examination. The matter is REMANDED for the following action: 1. Obtain and associate with this case file any outstanding VA medical records and all outstanding private treatment records, with all necessary assistance from the Veteran. 2. After the above development is completed, schedule the Veteran for a VA examination for the purpose of determining the nature and etiology of his claimed residuals of a head injury and scar. The claims file must be made available to the examiner for review in connection with the examination. Following a review of the relevant evidence, a history obtained from the Veteran, the clinical evaluation, and any tests that are deemed necessary, the examiner must diagnose all residuals of head trauma found to be present. For any diagnosed residuals of head trauma, the examiner must opine whether it is at least as likely as not (a 50 percent or greater probability) that the disability began during or is causally related to service, to include as due to the claimed head trauma sustained in 1976 while on a mountain climb in Korea. The examiner must also provide an opinion as to whether it is at least as likely as not that any scar on his head was incurred in or otherwise related to his period of active duty service. A full rationale for any expressed medical opinion must be provided. The examiner is advised that the Veteran is competent to report injuries and symptoms and that his reports must be considered in formulating the requested opinions. The examiner must specifically discuss the Veteran’s claimed in-service fall, and his reported headaches since that time, in the context of any negative opinion. 3. The Veteran must also be afforded a VA psychiatric examination for the purpose of determining the nature and etiology of his psychiatric disability. The claims file must be made available to the examiner for review in connection with the examination. Following a review of the relevant evidence, the examiner must opine whether it is at least as likely as not (a 50 percent or greater probability) that any diagnosed psychiatric disability began during or is causally related to service, to include as due to a 1976 fall from a mountain. The examiner must specifically address and consider the May 2014 diagnosis of depressive disorder as well as the verified in-service stressor of record – exposure to a traumatic event in August 1976 where the Veteran’s military buddies were killed in Korea. The examiner is advised that the Veteran is competent to report injuries and symptoms and that his reports must be considered in formulating the requested opinion. CAROLINE B. FLEMING Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD G.C., Associate Counsel