Citation Nr: 21041030 Decision Date: 07/07/21 Archive Date: 07/07/21 DOCKET NO. 18-15 360 DATE: July 7, 2021 REMANDED Entitlement to service connection for residuals of a head injury (claimed as a traumatic brain injury (TBI)) is remanded. REASONS FOR REMAND The Veteran served honorably in the United States Marine Corps from December 1979 to August 1983. His period of service from August 1983 to July 1995 was under Other Than Honorable conditions. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2017 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran contends that he sustained a head injury while in service. He reports that he was assaulted during service, when his SSGT hit him in the head with a stick. Service treatment records (STRs) from July 1980 show that the Veteran reported trauma to the back of the head and was assaulted by SSGT. He states he has residuals of that injury including a TBI, memory loss, and headaches. A VA medical opinion was obtained in November 2016. The VA examiner determined that the Veteran's memory loss and headaches were less likely than not proximately due to or the result of a TBI. Such was based on the finding that there were no documents supporting that a TBI occurred in service, and that there was no medical evidence that relating any current problem, to include memory loss, headaches, and tremors, to a TBI. The examiner failed to reconcile this findings with STRs that show that the Veteran was seen for complaints of trauma to the head with a report of loss of consciousness and related findings pertaining to difficulty with coordination and complaints of dizziness. Moreover, since that examination, records were received that appear to document the Veteran having some type of cognitive impairment including memory problems. For these reasons the November 2016 VA examination is deemed inadequate. A new examination and opinion is warranted. The matter is REMANDED for the following action: Schedule a VAX for the Veteran to determine the nature and etiology of the claimed residuals of a head injury. All indicated tests and studies necessary, including magnetic resonance imaging (MRI), computed tomography (CT), and neuropsychological testing should be accomplished (with all results made available prior to the completion of the examination report), and all clinical findings must be reported in detail. If the examiner is unable to conduct the required testing or concludes that any required testing is not necessary in this case, he or she should clearly explain so in the report. Copies of all pertinent records including this REMAND must be made available to and reviewed by the examiner. The VA examiner must provide the following opinions: a. Identify any current cognitive or neurological disability or disorder that presently exists or that has existed during the appeal period. The clinical significance of the records documenting complaints of memory loss, headaches, difficulty concentrating, anxiety, depression, and a sense of imbalance must be discussed. If no cognitive or neurological disorder is identified, rationale must be provided to support such a conclusion. b. For any identified cognitive or neurological disorder, state whether is at least as likely as not (a 50 percent or greater probability) that any diagnosed disability had its onset in or is otherwise related to active duty. There must be discussion of the documented report of a head injury in July 1980. The examiner should provide rationale for all opinions expressed. If the examiner is unable to provide an opinion without resorting to speculation, then the examiner must state whether the inability is due to the limits of the examiner's knowledge, the limits of medical knowledge in general, or there is additional evidence that, if obtained, would permit the opinion to be provided. MICHAEL A. HERMAN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Smith, 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.