Citation Nr: 21040539 Decision Date: 07/05/21 Archive Date: 07/05/21 DOCKET NO. 15-32 884 DATE: July 5, 2021 REMANDED Entitlement to service connection for headaches, to include tension headaches and migraines is remanded. Entitlement to service connection for a gastrointestinal disorder, to include gastritis with rectal prolapse, diarrhea, constipation, and history of functional bowel disease and black stool is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Air Force from May 1961 to May 1965. These matters originally came before the Board of Veterans' Appeals (Board) on appeal from a November 2013 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a hearing before the undersigned Veterans Law Judge (VLJ) in March 2019. A transcript of the hearing is associated with the claims file. The Board remanded this case in September 2019 to obtain VA examinations, and again in September 2020 and March 2021 for addendum opinions. 1. Entitlement to service connection for headaches, to include tension headaches and migraines is remanded. Once VA has provided a VA examination, it is required to provide an adequate one, regardless of whether it was legally obligated to provide an examination in the first place. Barr v. Nicholson, 21 Vet. App. 303 (2007). A VA examiner must consider the Veteran's lay statements regarding the incurrence of a disorder, and his statements regarding the continuity of symptomatology. Dalton v. Nicholson, 21 Vet. App. 23, 39-40. A Veteran is competent to report symptoms that are capable of lay witness observation. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). An addendum opinion for the Veteran's headaches was obtained in March 2021. The examiner opined the Veteran's headaches are less likely than not related to service. She explained that, "the veteran was hospitalized in 1964 and was found NOT to have a brain trauma. The veteran stated during the exam that he did not have headaches." However, this does not accurately reflect the evidence of record. Although the Veteran may not have noted a head trauma after his injury in 1964, he was hospitalized for two days under observation for a suspected head injury in May 1964, and again for two days under observation for a suspected cerebral concussion in July 1964. Additionally, the examiner said the 1964 headaches were not documented, his headaches were indirectly treated with medication used to treat other conditions, and that the Veteran said he did not have headaches. This also does not accurately reflect the evidence of record. Although the headaches may not have been documented, the Veteran testified at his March 2019 hearing that he did have headaches during and after service, and described his pain on active duty as "pressure on the side of my brain all the time." He also testified that he has been self-medicating over the years, and that his medication for other conditions has currently helped reduce the frequency of his headaches, but does not eliminate them. He stated that when he does get one, "I don't want to do anything except scream," and that he has to stay home in a dark room and use a cold compress. Therefore, the March 2021 VA examination is inadequate, and a remand is necessary to obtain a new opinion that addresses all of the evidence of record, including the Veteran's lay statements. 2. Entitlement to service connection for a gastrointestinal disorder, to include gastritis with rectal prolapse, diarrhea, constipation, and history of functional bowel disease and black stool is remanded. Once VA has provided a VA examination, it is required to provide an adequate one, regardless of whether it was legally obligated to provide an examination in the first place. Barr v. Nicholson, 21 Vet. App. 303 (2007). A VA examiner must consider the Veteran's lay statements regarding the incurrence of a disorder, and his statements regarding the continuity of symptomatology. Dalton v. Nicholson, 21 Vet. App. 23, 39-40. A Veteran is competent to report symptoms that are capable of lay witness observation. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). An addendum opinion for the Veteran's gastrointestinal disorder was obtained in March 2021. The examiner opined that the Veteran's gastrointestinal disorder is less likely than not related to service because he had a normal barium enema and resolved gastritis from service. She also explained that the Veteran's current symptoms of constipation and rectal prolapse are due to his age, and his diarrhea is likely due to taking too much of his constipation medication. However, the examiner did not fully address the Veteran's lay statements regarding his symptoms in service. The examiner noted there were no records of constipation or diarrhea in service and that his condition in service has long since resolved. However, the Veteran specifically stated at his March 2019 hearing that he had alternating constipation and diarrhea during and since service. His symptoms did not go away during or after service. He stated his symptoms were severe during the 1960's, 1970's, and 1980's, reduced for a while around 1990, and recently flared up again. The Veteran believes his rectal prolapse is caused by having severe constipation and diarrhea for decades. Therefore, the March 2021 VA examination is inadequate, and a remand is necessary to obtain a new opinion that addresses the Veteran's lay statements, including his statements regarding the continuity of symptomatology. The matters are REMANDED for the following action: 1. Obtain an addendum opinion for the Veteran's headaches, to include tension headaches and migraines, by a different physician (M.D.). The entire file should be made available to the examiner. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and assertions. The examiner must provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that any currently diagnosed headache disorder, to include tension headaches and migraines, had its clinical onset during active service or is related to any in-service disease, event, or injury, to include the Veteran's car accident in May 1964 and suspected concussion in July 1964. The examiner must also consider and address the Veteran's March 2019 hearing testimony regarding the Veteran's headaches during and after service, to include his symptoms in service of pressure on the side of his brain and after service, and reports of self-medicating. The examiner is requested to provide a clear rationale and explain in detail the underlying reasoning for any opinions expressed. A discussion of the facts and medical principles involved would be of considerable assistance to the Board. If an examiner cannot provide the requested opinion without resorting to speculation, he or she should expressly indicate this and provide a supporting rationale as to why an opinion cannot be made without resorting to speculation. 2. Obtain an addendum opinion for the Veteran's gastrointestinal disorder, by a different physician (M.D.). The entire file should be made available to the examiner. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and assertions. The examiner must provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that any currently diagnosed gastrointestinal disorder, to include IBS, with alternating diarrhea and constipation, had its clinical onset during active service or is related to any in-service disease, event, or injury, to include his reports of symptoms over the years at his March 2019 hearing. The examiner must specifically consider and address the Veteran's March 2019 hearing testimony regarding the Veteran's gastrointestinal symptoms during and after service, to include his alternating diarrhea and constipation throughout the 1960's, 1970's, and 1980's, and his recent flare ups. The examiner is requested to provide a clear rationale and explain in detail the underlying reasoning for any opinions expressed. A discussion of the facts and medical principles involved would be of considerable assistance to the Board. If an examiner cannot provide the requested opinion without resorting to speculation, he or she should expressly indicate this and provide a supporting rationale as to why an opinion cannot be made without resorting to speculation. TANYA SMITH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Papacalos, Associate 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.