Citation Nr: 18157075
Decision Date: 12/11/18	Archive Date: 12/11/18

DOCKET NO. 16-53 289
DATE:	December 11, 2018
REMANDED
Entitlement to service connection for residuals of a traumatic brain injury is remanded.
REASONS FOR REMAND
The Veteran served on active duty from February 1984 to February 1988.  This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a September 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, FL.  The Veteran appeared at a Board hearing before the undersigned Veterans Law Judge on June 2017.  A transcript of the hearing is in the Veteran’s file.
 Entitlement to service connection for residuals of TBI is remanded.
The Veteran claims entitlement to service connection for residuals of a TBI based upon a head injury during a security drill while serving on a ship.  The resulting injury required three stiches.
Service treatment records document a laceration on the head in August 1987.  There are no further treatment records for this head injury.  The Veteran testified at the hearing, describing symptoms over the years he believes to have been a consequence of the in-service head injury.  The Veteran asserts he realized he was having residuals of TBI after seeing someone on television with similar issues, and that he did not seek treatment until he was in the VA healthcare system in 2011.  
A VA examination from April 2014 did not indicate residuals of TBI.  The examiner pointed to three other head injuries in the Veteran’s life that required emergency medical treatment, including the one in service, but none were associated with any long term residuals of TBI, and that the Veteran had not manifested long-term chronic post-concussion TBI residual symptoms.  The examiner opined that it is less likely than not that the veteran’s claimed memory problems and past migraine headaches were caused by his in-service head injury.  
The Veteran stated during the hearing that he believed that because he appeared for the examination with withdrawal symptoms from alcohol use, the examiner did not have an accurate picture of his condition, and he requested another examination to be administered.  Given these factors and that the last examination was in 2014, another examination seems appropriate.
The matter is REMANDED for the following action:
1. Ask the Veteran to identify any additional records of treatment he wishes considered in connection with this appeal, which records should be sought.  
2. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any TBI residuals or other neurological disability characterized by the Veteran’s reported symptoms.  The claims file should be provided to the examiner for review.  For each diagnosis, the examiner is asked to opine whether it is at least as likely as not (i.e. 50 percent probability or greater) that the diagnosis is related to the Veteran’s service, and particularly the head trauma/laceration he sustained in August 1987.
3. A complete rationale for any opinion expressed should be provided.  If the examiner is unable to offer an opinion without resorting to speculation, the examiner should provide a rationale for that conclusion.
4. Then readjudicate the remanded claims.  If any of the benefits sought on appeal remain denied, furnish the Veteran and his representative with a Supplemental Statement of the Case and afford them the opportunity to respond before the file is returned to the Board for further consideration


 
MICHAEL KILCOYNE
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	B. Jaigirdar, Associate Counsel