BVA9508161 DOCKET NO. 93-12 238 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Des Moines, Iowa THE ISSUE Entitlement to service connection for a condition manifested by syncopal episodes. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Jeanne Schlegel, Associate Counsel INTRODUCTION The veteran performed honorable active naval service from August 1985 to July 1989. This matter comes before the Board of Veterans' Appeals (the Board) from a December 1991 rating determination by the Department of Veterans Affairs (VA) Regional Office (RO) which denied service connection for the veteran's syncopal episodes (fainting spells). REMAND The veteran has submitted a claim for entitlement to service connection for syncopal episodes. Preliminary review shows that crucial aspects of the record warrant development. As this development may produce evidence to support the appellant's theories of the case, his claims are "capable of substantiation," and are thus well-grounded at this point in time within the criteria set forth in the case law provided by the United States Court of Veterans Appeals. Murphy v. Derwinski, 1 Vet.App. 78 (1990). Once it has been determined that a claim is well grounded, the VA has a statutory duty to assist the appellant in the development of evidence pertinent to the claim. 38 U.S.C.A. § 5107. A determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or disease incurred in service. Watson v. Brown, 4 Vet.App. 309, 314 (1993). The veteran is presently service connected for chronic low back pain with herniated nucleus pulposus, L4-5, evaluated as 20 percent disabling, and stress fractures of both the right and left legs, each evaluated noncompensable. The veteran's 1984 pre-enlistment medical examination indicates that the veteran reported having had a head injury prior to service, which appears to have been a scalp laceration. However, no head or neurological abnormality was detected by the examiner upon clinical evaluation. Service medical records show that in January 1988, the veteran was going up a ladder while aboard ship and was hit on the head when a hatch lid fell. The record indicates that the veteran stopped most of the fall with his hands. No loss of consciousness was reported, as verified by a witness. An extremely superficial laceration over the distal left eyebrow, mild dizziness, and an abrasion to the back of the head resulted from this incident. Other records indicate that the veteran reported symptoms of vertigo in conjunction with hearing loss problems experienced in July 1988. In September 1988, the veteran was involved in an automobile accident. The medical entry noted complaints of pain in the lumbar spine and limited range of motion in the head due to pain. In October 1988 the veteran reported that he was having blackouts. Also in October 1988, the veteran was seen for a psychiatric evaluation, with a provision diagnosis of schizoid behavior. It was noted that the veteran had made 115 medical visits since July 1985 and that this fact together with other symptoms resulted in a diagnosis of personality disorder, however there was no specific mention with regard to the veteran's "blackouts." In December 1988, the veteran fell against a headboard striking the frontal area of his head. There was no loss of consciousness, but loss of coordination and balance were recorded, and he rrquired three stitches. An entry dated later that month on follow-up indicated that the head laceration was resolved, requiring no remaining need for a follow-up for this problem. In July 1989, the veteran again hit his head resulting in minimal bleeding, but no loss of consciousness of dizziness. The separation medical examination in July 1989 revealed no abnormality of the head nor any neurological or psychiatric abnormality recorded on clinical evaluation. The veteran reported that felt good except that his back and legs bothered him. He also gave a history of a head injury. A VA medical examination was performed in September 1989 in connection with the veteran's claims for a low back disability and bilateral stress fractures of the lower extremities. No complaints of syncopatic spells, dizziness, or blacking-out were mentioned. There were no significant neurological findings. A hearing was held at the RO in March 1990 with respect to the veteran's back and legs claims. The issue of blackouts was introduced and the veteran indicated that he had just started having blackouts "within the last two weeks." A clinical record from March 1990 indicated that the veteran had a history of frequent falls occurring on an almost a daily basis. He recalled vertigo on only a couple of occasions and had noted some lack of coordination. It was indicated by the orthopedic examiner that his symptoms did not seem to be the result of his back condition, but could be neurological. By May 1990, it was recorded that the veteran had fallen 20 to 30 times in the last month and had experienced several episodes where "everything stopped." The veteran was hospitalized at a VA facility for most of May 1990 for evaluation of his "syncopal spells" and falling attacks without loss of consciousness. He reported that the attacks occurred 2 to 3 times a day and that he hurt his head on occasion, but never convulsed or had loss of sphincter tone or tongue biting. His falling attacks were sometimes associated with back pain in the lumbar area. An MRI in May 1990 showed a pineal cyst; however, the examiners were unable to define any clear etiology for his symptoms. Neurosurgical consultation concluded that his symptoms were not clearly related to any surgically correctable pathology. Following neuro-ophthalmology, psychology, and psychiatry consultations, the veteran was diagnosed with falling episodes of unclear etiology. In September 1990, the veteran's syncopal condition was again assessed. A history of head trauma a year and a half ago was noted, along with muscular back pain and dizzy spells. It was remarked in this entry that given the associated symptoms, the spells most closely appeared to be panic attacks. The veteran was hospitalized at a VAMC for four days in October 1991 resulting again in a diagnosis of falling episodes of unknown etiology. The MRI was negative, and bone scan and an "Echo" of the head were normal. It is not clear if any medical records, particularly service records were reviewed during this hospitalization, as none were referenced. At a July 1992 hearing the veteran testified that he was experiencing black-outs two or three times a day. The veteran was most recently hospitalized at a VAMC for four days in February 1993. The veteran again presented a history of "spells" since being hit on the head by a large hatch in service in 1988. It was recorded that initially on his admission, there were no records from previous hospitalizations. However, these records arrived, and were reviewed, at which point it became clear that he had been given multiple workups in the past for the same symptoms, all resulting in normal findings, yielding no clear diagnosis. Again the diagnosis given at the time of this hospitalization was "spells, etiology undetermined." Although this file contains copious in-service and post service medical records, there is no evidence of record which considers the possibility of a link between the veteran's on-going syncopal episodes and the residual symptoms of the veteran's in-service injuries. It appears that although many examinations and hospitalization evaluations have taken place and often a history provided by the veteran was recorded, the prior medical records (particularly service records) were not carefully reviewed and in some cases may not have been available. A review of these prior records and of particular importance, the service records pertaining to the falls and accidents which the veteran alleges are the cause of his current syncopal condition, is necessary to the adjudication of this veteran's claim of entitlement to service connection for syncopal spells. The Board is of the opinion that the duty to assist the appellant in this case includes conducting a thorough and contemporaneous medical examination, one which includes taking into account the records of prior medical treatment, and in this case particularly the service medical records, so that the evaluation of the appellant's claim will be a fully informed one. Green v. Derwinski, 1 Vet.App. 121, 124 (1991). Such an examination is particularly warranted in light of the varying diagnoses and conflicting and diverse assessments of the veteran's syncopic episodes, which have yet to be associated with any etiology. Cousino v. Derwinski, 1 Vet.App. 536, 540 (1991). Where the record before the Board is inadequate to render a fully informed decision on the issues in appellate status, as it is here, a remand to the RO is required in order to fulfill the statutory duty to assist. See Ascherl v. Brown, 4 Vet.App. 371, 377 (1993). In light of the foregoing, the Board finds that further development, as specified below, is warranted. Accordingly, the case is REMANDED to the RO for the following: The RO should refer this case to a specialist in neurology for an evaluation, as well as a specialist in psychiatry (if deemed necessary) in order to determine the nature, severity, and etiology of the veteran's disability manifested by syncopal episodes. In particular, the examiner(s) should be requested to review a copy of this REMAND and the two volume claims folder in conjunction with the evaluation, paying particular attention to those in- service incidents and pertinent symptoms, cited by the veteran as the cause of his current condition. An opinion should be requested whether it is as likely as not that the veteran's syncopal episodes are causally related to an injury, clinical finding or symptom of service origin. In arriving at such opinion, the examiner(s) should indicate the degree to which they may have relied upon the objective documentation of record, as opposed to history reported by the appellant. All indicated testing, deemed necessary, should be conducted and the results reported in detail. Thereafter, the case should be reviewed by the RO. If the benefit sought is not granted, a supplemental statement of the case should be issued to the appellant and his representative and they should be provided an opportunity to respond thereto. Subsequently, the claims folder should be returned to the Board for further review, if necessary. By this action, the Board intimates no opinion, either legal or factual, as to the ultimate disposition warranted as to this specific issue. J. F. GOUGH Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. Under 38 U.S.C.A. § 7252 (West 1991), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Veterans Appeals. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (1994).