Citation Nr: 21023155 Decision Date: 04/20/21 Archive Date: 04/20/21 DOCKET NO. 15-06 738 DATE: April 20, 2021 ORDER Entitlement to service connection for recurrent head trauma residuals, other than scar residuals, is denied. REMANDED Entitlement to service connection for a recurrent liver disability, to include a fatty liver, is remanded. Entitlement to service connection for a recurrent abdominal disability, to include recurrent right lower quadrant pain, is remanded. FINDINGS OF FACT 1. Service connection has been established for head injury scalp scar residuals. 2. Recurrent head injury residuals, other than scar residuals, were not shown during active service or at any time thereafter. CONCLUSION OF LAW The criteria for service connection for recurrent head trauma residuals, other than scar residuals, have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran had active service from July 1993 to July 2013. Service Connection Service connection may be granted for recurrent disability arising from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110. Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Recurrent Head Injury Residuals Other Than Scar Residuals The Veteran contends that service connection for recurrent head injury residuals, other than scar residuals, is warranted as he sustained inservice head trauma when he struck his head on an antenna while working under an aircraft on two different occasions and subsequently experienced impaired memory following service separation. The service treatment records reflect that the Veteran sustained inservice head trauma. Clinical documentation dated in April 1998 state that the Veteran sustained a scalp laceration after walking into an aircraft antenna. No loss of consciousness or other associated trauma was noted. The laceration was secondarily closed. A November 2012 treatment record states that the Veteran sustained a superficial head wound after hitting his head on an aircraft antenna. The wound was secondarily closed. Service connection has been established for head injury scalp scar residuals. Recurrent head trauma residuals, other than scar residuals, have not been shown during active service or at any time thereafter. The Veteran asserts that the claimed recurrent head trauma residuals are manifested by some memory impairment. The reports of Department of Veterans Affairs (VA) examinations conducted in May 2013, January 2015, March 2015, and January 2019 indicate that the Veteran complained of occasional difficulty finding words and recalling specific details from conversations. The examiners all found that the Veteran did not exhibit recurrent head trauma residuals including either recurrent traumatic brain injury (TBI) residuals; significant memory impairment inconsistent with his age; or recurrent headaches. The report of a December 2019 TBI examination conducted for VA states that the examiner was a physiatrist. The examiner concluded that that the Veteran had not sustained a TBI and exhibited no recurrent TBI residuals. He commented that “medical documentation doesn’t document any symptoms related to a head injury that meets criteria for a diagnosis of TBI.” The Veteran asserts that service connection for head trauma residuals, other than scar residuals, is warranted as he sustained documented inservice head trauma. While the service treatment records document that the Veteran sustained two head lacerations when he struck his head on aircraft antenna, the inservice and post service clinical documentation does not show any non scar residuals of the documented head trauma. No competent medical professional has concluded that the Veteran has any head trauma residuals other than the service connected scar residuals. The Veteran’s claim is supported solely by his own statements on appeal. Lay assertions may serve to support a claim for service connection by establishing the occurrence of observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C. § 1154(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F. 3d 1331 (Fed. Cir. 2006). Lay evidence can be competent and sufficient to establish a diagnosis or etiology when (1) a lay person is competent to identify a medical condition; (2) the lay person is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The Board of Veterans’ Appeals (Board) finds that the Veteran’s lay statements do not constitute competent evidence to establish a diagnosis of recurrent non scar head trauma residuals given the absence of any clinical documentation of such disability. The Veteran has not offered any medical qualifications. The Veteran is not competent to offer an opinion regarding the existence of recurrent head injury residuals including impaired memory and the relationship of such disability to active service. The question of the diagnosis of such a disability requires medical training and is too complex to be addressed by a layperson. Medical professionals considered his contentions and found no current disability. The Veteran has not submitted any competent evidence showing any recurrent head trauma residuals other than the service connected head trauma scar residuals. Recurrent head trauma residuals, other than scar residuals, were not manifested during active service or at any time thereafter. As the preponderance of the evidence is against the claim, the Board finds that service connection for recurrent head trauma residuals, other than scar residuals, is not warranted, and the claim is denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Entitlement to service connection for a liver disability, to include a fatty liver, is remanded. The service treatment records note that the Veteran was treated for alcohol abuse and found to have an enlarged and fatty liver. The report of a December 2019 liver examination conducted for VA states that the Veteran was diagnosed with “fatty liver.” The examiner concluded that “it is at least as likely than not that the Veteran has a diagnosis of a fatty liver that was incurred in service” and “medical documentation has reported diagnosis of fatty liver during service.” The physician did not clarify whether the diagnosis of a fatty liver was a clinical finding or represented a recurrent liver disability and the relationship, if any, to the documented inservice alcohol abuse. Therefore, the Board finds that the examination report is of limited probative value. VA’s duty to assist includes, in appropriate cases, the duty to conduct a thorough and contemporaneous medical examination which is accurate and fully descriptive. McLendon v. Nicholson, 20 Vet. App. 79 (2006); Green v. Derwinski, 1 Vet. App. 121, 124 (1991). When VA undertakes to obtain an evaluation, it must ensure that the evaluation is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Therefore, the Board finds that further VA liver examination is needed. 2. Entitlement to service connection for a recurrent abdominal disability, to include recurrent right lower quadrant pain, is remanded. Service connection may be granted for disability which is proximately due to or the result of a service connected disease or injury. 38 C.F.R. § 3.310(a). Service connection shall be granted on a secondary basis under the provisions of 38 C.F.R. § 3.310(a) where it is demonstrated that a service connected disorder has aggravated a nonservice connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). Service connection has been established for appendectomy scar residuals, nephrolithiasis, a panic disorder, right knee strain, left knee strain, right ankle fracture and strain residuals, left wall strain, allergic rhinitis, right ear hearing loss, tinnitus, and head injury scar residuals. The Veteran has not been afforded a VA examination to determine the relationship, if any, between the documented inservice and post-service right lower abdominal pain and the appendectomy scar residuals, nephrolithiasis, and the other service connected disabilities. Clinical documentation dated after August 2019 is not of record. VA should obtain all relevant VA and private treatment records which could potentially be helpful in resolving the Veteran’s claims. Murphy v. Derwinski, 1 Vet. App. 78 (1990); Bell v. Derwinski, 2 Vet. App. 611 (1992). The matter is REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for each private healthcare provider who has treated any liver and abdominal disabilities. Make two requests for the authorized records from all identified healthcare providers unless it is clear after the first request that a second request would be futile. 2. Obtain any VA treatment records not of record, to include those pertaining to treatment after August 2019. 3. Schedule the Veteran for a VA liver examination conducted by a medical doctor to assist in determining the current nature of any identified recurrent liver disability and any relationship to active service. The examiner must review the record and should note that review in the report. A rationale for all opinions should be provided. The examiner should: (a) Diagnose all liver disabilities found. If a fatty liver is identified, the examiner should specifically state whether such a finding is a manifestation of a recurrent liver disability. (b) Opine whether it is at least as likely as not (50 percent probability or greater) that any identified liver disability had its onset during active service or is related to any incident of service, including the documented inservice fatty liver and alcohol abuse. 4. Schedule the Veteran for a VA examination conducted by an appropriate medical doctor to assist in determining the current nature of any identified right lower abdominal disability and any relationship to active service or a service-connected disability. The examiner must review the record and should note that review in the report. A rationale for all opinions should be provided. The examiner should: (a) Diagnose all recurrent right lower abdominal disabilities found. If no disability is found, the examiner should specifically state that fact. (b) Opine whether it is at least as likely as not (50 percent probability or greater) that any identified recurrent right lower abdominal disability had its onset during active service or is related to any incident of service. (Continued on the next page)   (c) Opine whether it is at least as likely as not (50 percent probability or greater) that any identified recurrent right lower abdominal disability is due to or caused by the appendectomy residuals, nephrolithiasis, and the other service-connected disabilities. (d) Opine whether it at least as likely as not (50 percent probability or greater) that any identified recurrent right lower abdominal disability has been aggravated (increased in severity beyond the natural progress of the disorder) by the appendectomy residuals, nephrolithiasis, and the other service-connected disabilities. J. T. HUTCHESON Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Ferguson, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.