## Facts

- Victor G. Green contracted poliomyelitis during active military service in 1947, with service records documenting significant neuromuscular weakness in multiple muscle groups.
- Decades later, Green sought VA service-connected disability compensation for (1) a psychotic condition and (2) residuals of poliomyelitis, asserted primarily as a left-leg disorder.
- A January 15, 1988 VA neurologic examination reported objective left-leg abnormalities, including smaller size than the right, an abnormal gait favoring the left leg, muscle wasting below the knee, diminished muscle strength, and diminished deep tendon reflexes bilaterally.
- The examiner expressed diagnostic uncertainty about whether the current findings were related to the in-service poliomyelitis and indicated that additional diagnostic studies could help resolve the question.
- The VA Regional Office denied both claims, and the Board of Veterans’ Appeals (BVA) affirmed both denials without ordering further diagnostic testing or a clarifying examination regarding polio residuals.
- Green appealed the BVA decision.

## Issues

1. Whether the BVA committed reversible error in denying service connection for Green’s current psychotic condition.
2. Whether the BVA erred in denying service connection for residuals of poliomyelitis without obtaining an adequate medical examination and any advisable diagnostic studies, consistent with VA’s duty to assist.

## Decision

- The court affirmed the BVA’s denial of service connection for the psychotic condition.
- The court vacated the BVA’s denial of service connection for residuals of poliomyelitis and remanded for further development and readjudication.
- On remand, VA was required to obtain a thorough and contemporaneous medical examination, including any indicated diagnostic studies, to permit a fully informed adjudication of the polio-residuals claim.

## Legal Principles

- VA’s duty to assist under 38 U.S.C. § 5107(a) requires assistance in developing facts pertinent to a well-grounded claim.
- Under appropriate circumstances, the duty to assist includes providing a thorough and contemporaneous medical examination.
- An adequate examination must consider the claimant’s prior medical records so that the disability evaluation is fully informed.
- When an examination reflects diagnostic uncertainty and indicates that further testing could be helpful to resolve a material medical question, VA may not deny the claim on an incomplete medical record without obtaining the necessary clarification and studies.

## Conclusion

The court upheld the denial of service connection for a psychotic condition but held that VA failed its duty to assist on the poliomyelitis-residuals claim by relying on an equivocal examination without completing recommended development; it therefore vacated and remanded for an adequate, fully informed medical evaluation and readjudication.


Green v. Derwinski, 1 Vet. App. 121 (1991)