Citation Nr: 1539127 Decision Date: 09/14/15 Archive Date: 09/24/15 DOCKET NO. 11-09 819 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Milwaukee, Wisconsin THE ISSUES 1. Entitlement to service connection for a skin disability. 2. Entitlement to service connection for tinnitus. 3. Entitlement to an initial rating in excess of 50 percent for posttraumatic stress disorder (PTSD) with depression. 4. Entitlement to a rating in excess of 40 percent for status post gastrectomy with Roux-en-Y procedure, and B12 anemia associated with gastric lymphoma. 5. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Wisconsin Department of Veterans Affairs ATTORNEY FOR THE BOARD P. Lopez, Associate Counsel INTRODUCTION The Veteran served on active duty from December 1967 to November 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from October 2009, December 2009, and June 2011 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Milwaukee, Wisconsin. In the October 2009 decision, the RO granted service connection for depressive disorder and assigned an initial rating of 30 percent (since increased to 50 percent). That decision also continued a 20 percent rating for status post gastrectomy with Roux-en-Y procedure, and B12 anemia associated with gastric lymphoma. The Veteran appealed both issues in a March 2010 notice of disagreement; in that correspondence he indicated that an increase to a 40 percent rating for the gastrointestinal condition would satisfy his appeal. Such increase was ultimately implemented in June 2011; however, as the Veteran immediately appealed that rating assignment the Board finds that the appeal dates back to the October 2009 decision (in other words, the Board will choose to ignore the limitation placed on his appeal as he acted inconsistently with such limit). Next, a December 2009 decision denied service connection for a skin disability and tinnitus. In the June 2011 decision, it assigned an initial rating of 50 percent for the Veteran's service-connected mental health disability and a rating of 40 percent for status post gastrectomy with Roux-en-Y procedure and B12 anemia. The Veteran requested a Board hearing. See April 2011 and July 2014 substantive appeals. A hearing was scheduled for April 2015. On the day of the hearing, the Veteran's representative stated that the Veteran was unable to report due to his mental health condition and submitted arguments on the Veteran's behalf. As such, the Board finds that the Veteran withdrew his request for a hearing. The claims file is now entirely contained in VA's secure electronic processing systems, Virtual VA and Veterans Benefits Management System (VBMS). The issue of service connection for a skin disability is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The weight of the evidence is against a finding that the Veteran's claimed tinnitus symptoms are pathological in nature. 2. The weight of the evidence shows that the Veteran's service-connected PTSD with depression resulted in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to symptoms of a nature and severity most nearly approximating those contemplated by a 70 percent disability rating. 3. The Veteran's service-connected PTSD with depression did not result in total social and occupational impairment. 4. The weight of the evidence shows that the Veteran's service-connected post status gastrectomy with Roux-en-Y procedure and B12 anemia associated with gastric lymphoma resulted in symptoms most nearly approximating those contemplated by a 60 percent disability rating. 5. The Veteran's service-connected disabilities are as likely as not of such nature and severity as to prevent him from securing or following substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for service connection for tinnitus have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112(a), 1137, 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2014). 2. The criteria for a rating of 70 percent, but no higher, for PTSD, during the entire appeal period, have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.321(b)(1), 4.3, 4.7, 4.10, 4.126, 4.130, Diagnostic Code 9411 (2014). 3. The criteria for a rating of 60 percent for post status gastrectomy with Roux-en-Y procedure and B12 anemia have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.114, Diagnostic Code 7308 (2014) 4. The criteria for an award of TDIU have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.3, 4.15, 4.16 (2014). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to Notify and Assist The Veteran was provided complete notice with regard to his service connection and increased rating claims in June 2009, prior to the initial adjudications. See 38 U.S.C.A. § 5103; 38 C.F.R. § 3.159(a). Concerning the duty to assist, all identified, pertinent treatment records have been obtained and considered. The Veteran was afforded a VA examination in November 2009 to determine the nature and etiology of his hearing disability. He was also afforded VA examinations in May 2011, June 2012, and May 2014 to determine the severity of his mental health disability and post status gastrectomy. The Board finds that these examinations were adequate, and there is no argument to the contrary. VA has satisfied its duties to inform and assist with respect to this claim. There is no additional notice or assistance that would be reasonably likely to aid in substantiating the claim, and there will be no prejudice by a decision. II. Analysis Service Connection for Tinnitus Service connection will be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Where a disease is first diagnosed after discharge, service connection will be granted when all of the evidence, including that pertinent to service, establishes it was incurred in active service. 38 U.S.C.A. § 1113(b); 38 C.F.R. § 3.303(d). Service connection requires evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the condition incurred or aggravated by service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). A nexus between a current disability and an in-service injury may be established by evidence of continuity of symptomatology, if the condition is a chronic disease enumerated under 38 U.S.C.A. § 1101. Walker v. Shinseki, 708 F.3d 1331, 1338-40 (Fed. Cir. 2013). Tinnitus is considered an organic disease of the nervous system, and as such is an enumerated chronic disease. See 38 U.S.C.A. §§ 1101, 1112; Memorandum, Characterization of High Frequency Sensorineural Hearing Loss, Under Secretary for Health, October 4, 1995; 38 C.F.R. §§ 3.307, 3.309. When there is an approximate balance of positive and negative evidence regarding any material issue, or the evidence is in relative equipoise, all reasonable doubt will be resolved in favor of the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. The Veteran has stated that he has symptoms of tinnitus. He believes that his tinnitus is related to hazardous noise exposure in service. His military occupational specialty was carpenter. See DD Form 214. The Board concedes the claimed hazardous noise exposure. The Veteran is competent to report his observable symptoms and history, including when he first perceived ringing in the ears; and such reports must be considered. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Nevertheless, he is not competent to offer an opinion as to the nature and etiology of his hearing disability, as that requires specialized medical expertise. Id.; 38 C.F.R § 3.385. He is competent to report a diagnosis and a continuity of symptomatology of tinnitus. Charles v. Principi, 16 Vet. App. 370, 374 (2002). During the November 2009 VA examination, the Veteran reported that he has had intermittent tinnitus in both ears since service. He stated that it occurred three to four times per day and lasted for a minute or less. The examiner opined that the Veteran's tinnitus was more likely than not unrelated to his military noise exposure. Significantly, the examiner also stated that the tinnitus described by the Veteran is not unlike that of the normal hearing population. It was of a random nature and short in duration, and therefore deemed nonpathologic. In sum, the most probative evidence shows that the Veteran does not have a current disability with respect to his tinnitus claim. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (disallowing service connection where there was no current disability). While generally lay evidence is sufficient to establish tinnitus, as there is no specific medical test to indicate its presence or absence, here the examiner was able to deduce from the Veteran's competent descriptions that the tinnitus was nonpathologic in nature and thus not a disability. As this finding came from a medical professional it is deemed dispositive and has not been refuted by any other medical evidence of record. Thus, the preponderance of the evidence is against service connection or benefits under 38 U.S.C.A. § 1151, the benefit of the doubt doctrine does not apply, and the claim for tinnitus must be denied. 38 C.F.R. §§ 3.102, 3.303. Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The percentage ratings are based on the average impairment of earning capacity as a result of a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. All reasonable doubt as to the degree of the disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3. In determining the propriety of an initial disability rating, the evidence since the effective date of the grant of service connection must be evaluated and staged ratings must be considered. Fenderson v. Brown, 12 Vet. App. 119, 126-27 (1999). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The Board must also consider staged ratings, which are appropriate when the evidence establishes that the claimed disability manifested symptoms that would warrant different ratings for distinct time periods. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided; however, separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of or overlapping with the symptomatology of the other. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 262 (1994). PTSD Evaluation of a mental disorder requires consideration of the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the capacity for adjustment during periods of remission. Evaluations will be assigned based on all evidence that bears on occupational and social impairment, rather than solely on an examiner's assessment of the level of disability at the moment of the examination. The extent of social impairment shall also be considered, but an evaluation may not be assigned based solely on the basis of social impairment. 38 C.F.R. § 4.126. Percentage ratings for service-connected mental health disabilities are based on the criteria in the General Rating Formula for Mental Disorders. See 38 C.F.R. § 4.130. The symptoms listed in 38 C.F.R. § 4.130 are not intended to constitute an exhaustive list but, rather, serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating for a mental disorder. The Board notes that the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) was recently issued and applies to all claims that were pending before the RO on or after August 4, 2014, as was the case here. This version of the DSM no longer relies on Global Assessment of Functioning (GAF) scores and thus such evidence will not be considered in evaluating the claim. The Veteran's service-connected PTSD has been assigned an initial 50 percent rating, effective January 30, 2009. Resolving doubt in favor of the Veteran, the Board finds that he meets the criteria for a rating of 70 percent, but no higher. The criteria for a 70 percent rating are as follows: Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. Id. The criteria for a 100 percent rating are as follows: Total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. For the entire appeal period, the medical and lay evidence shows that the Veteran's disability has manifested as irritability, anhedonia, anxiety, depression, poor sleep, hyperarousal, marital difficulties, suicidal thoughts, and avoidance of crowds. A January 2009 VA mental health note shows that the Veteran reported problems with anger, irritability, anhedonia, anxiety, and poor sleep for years. He also reported hyperarousal and stated that his wife was about to leave him if he did not get help. The author noted that the Veteran was alert, oriented, neatly dressed and groomed, guarded and anxious, and spoke at normal rate. Flow of thought and concentration were normal, memory appeared intact, and there were no hallucinations or delusions. He had a constricted affect, with fair judgment and insight. A February 2009 addendum notes a poor relationship with his wife. A March 2009 VA mental health note shows a report of suicidal thoughts, usually after a fight with his wife. The Veteran also stated that he avoids crowds and gave up all hobbies two years earlier. He lived with his wife and daughter, both of whom he fights with, and that the only thing keeping him there was his dog, with whom he has the closest relationship. An April 2009 VA mental health note shows that the Veteran was feeling better, with improved sleep and appetite, and reduced anxiety. His relationship with wife and daughter was slightly better. He denied suicidal ideation and stated that overall he was doing well. A June 2009 VA mental health note shows that relationship with his wife had improved, but the relationship with daughter remained strained. He also reported improved sleep. Otherwise, condition had not changed. VA mental health notes from August and September 2009 show continued problems at home. His mood was stable and sleep and appetite were normal. He stated that he was not having any nightmares but still had a heightened startle reflex and avoided crowds. He also reported flashbacks, which the examiner interpreted as memories rather than reliving experiences. His relationships with his family were a major source of concern. He denied suicidal ideation and reiterated that his closest relationship was with his dog. The Veteran denied any significant impact on his functioning. A November 2009 VA mental health note shows continued issues with wife and daughter. The Veteran reported having an argument with his wife over her wish to sleep in separate rooms. Overall, his mood was stable, with occasional depression and irritation. Sleep and appetite were generally normal. He denied overvigilance, but still avoided crowds. The Veteran was afforded a VA examination in May 2011. The examiner noted symptoms of depressed mood, chronic sleep impairment, flattened affect, impaired abstract thinking, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, suicidal ideation, neglect of personal appearance and hygiene, difficulty in adapting to stressful circumstances, including work or a worklike setting, inability to establish and maintain effective relationships, loss of interest, loss of pleasure in usual activities, weight loss, fatigue, loss of energy, feelings of worthlessness, some diminished ability to maintain his attention on tasks or avocational activities. The examiner noted occupational and social impairment with reduced reliability and productivity. Regarding functional impact, the Veteran reported being less and less able to focus on work tasks, and recall sequence of work assignments. He was chronically weak, tired, and irritable, and that he lost several jobs because he exploded at co-workers and customers, for which reason he was unemployed. A June 2012 VA examination shows symptoms of depressed mood, flattened affect, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. The examiner noted that the Veteran's psychiatric symptoms were not severe enough either to interfere with occupational and social functioning or to require continuous medication. The Veteran was alert and showed no signs of confusion. He appeared oriented to person, time, and place. Conversational speech was fluent, without paraphasic error or significant word finding problems. Grammar and syntax were intact. A full range of affect was evident. His mood was mildly dysthymic and thoughts were linear and goal directed. There were no signs of a thought disorder. Grooming and hygiene were within normal limits and appreciation of personal problems and deficits was good. Eye contact was good. There were no abnormal motor movements evident. The Veteran interacted appropriately with the examiner. He described his mood as depressed and stated that he had trouble with attitude, anger, dissatisfaction, boredom, and irritability. He also claimed that he was unemployable due to his anger and irritability. He described depressed mood most of the day nearly every day by saying that he feels sad and tearful when he talked about the loss of his mother and the recent loss of his best friend. He reported markedly diminished interest in almost all activities but stated that he still hunts with his brother, fishes once or twice a year, goes to church on special occasions, and goes to restaurants primarily with an 84 year-old friend. His reported sleep schedule did not reflect chronic insomnia or hypersomnia. He expressed no feelings of worthlessness or excessive or inappropriate guilt. He did not report any diminished ability to think, concentrate, or take decisions. He did not report recurrent thoughts of death and stated that although he has thought about suicidal ideation, he thought that suicide was a stupid choice. The examiner noted that the Veteran's depression did not seem worse than in the prior VA examination and he continued to function without much restriction in his activities. The examiner opined that the Veteran's depressive disorder did not prevent him from being employed in a sedentary capacity, given his multiple medical problems. A May 2014 VA examination shows continued symptoms of depressed mood. The examiner noted occupational and social impairment with reduced reliability and productivity. The Veteran was still married, but described the relationship as rocky, as he had little in common with his spouse and they spent little time together; he expected to divorce. He described his relationship with his disabled grown-up daughter as 50-50. The examiner noted that the Veteran's mental health disability would impose mild to moderate impairment on any type of employment due to his depression and PTSD symptoms, including interpersonal difficulties. Cognitive abilities remained intact, including memory, judgment, insight, and abstract functions. The Veteran was not taking psychotropic medication. He denied suicidal or homicidal ideation. In sum, the Veteran's disability picture, as described above, is found to most nearly approximate the criteria for a 70 percent rating during the appeal period. The evidence of record, however, does not warrant a rating higher than 70 percent for any portion of the appeal period. In this regard, the Veteran's thought processes and communication have consistently been within normal levels. There are no reports of grossly inappropriate behavior or an inability to perform activities of daily living, disorientation to time or place, or memory loss for names of close relatives, own occupation or own name. Although some evidence reflects that Veteran is unable to work due to his PTSD, his symptoms have not resulted in total occupational and social impairment. In this regard, the evidence shows that the Veteran has remained married even though he has consistently reported marital difficulties, has a close friend with whom he socializes on a regular basis, and reported going hunting with his brother. As such, the Board finds that the Veteran's PTSD with depression has not resulted in total social impairment. In sum, the evidence does not establish total social or occupational impairment due to the Veteran's PTSD, so as to warrant the higher rating of 100 percent. As such, the Board finds that the Veteran's symptomatology most nearly approximates the criteria for a 70 percent rating during the entire appeal period. Staged ratings have been considered, but are not warranted, as the Veteran's symptomatology remained relatively stable during the appeal period. Any increases in severity were not sufficient for a higher rating for the reasons discussed above. Hart, 21 Vet. App. at 509-10. Extraschedular consideration is not warranted under 38 C.F.R. § 3.321(b)(1). The Veteran has social and occupational impairment as a result of his PTSD. Such symptomatology is fully contemplated by the schedular rating criteria. Therefore, the rating schedule is adequate, it is not an exceptional or unusual disability picture, and referral for consideration of an extraschedular rating is not necessary. Thun v. Peake, 22 Vet. App. 111, 115-16 (2008). The Board notes that under Johnson v. McDonald, 762 F.3d 1362 (2014), a Veteran may be awarded an extraschedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the individual conditions fails to capture all the service-connected disabilities experienced. In this case, however, after applying the benefit of the doubt under of Mittleider v. West, 11 Vet. App. 181 (1998), there are no additional symptoms stemming from other service-connected disabilities that have not been attributed to the specific service-connected condition on appeal where there is any doubt as to their origin. Accordingly, this is not an exceptional circumstance in which extraschedular consideration may be required to compensate the Veteran for a disability that can be attributed only to the combined effect of multiple conditions. A higher initial rating of 70 percent for PTSD for the entire appeal period, is being granted based, in part, on application of the benefit-of-the-doubt doctrine. The preponderance of the evidence, however, is against a rating higher than 70 percent during the entire appeal period. Therefore, reasonable doubt does not arise, and the claim must be denied in this respect. 38 C.F.R. § 4.3. Status Post Gastrectomy Service connection for status post gastrectomy with Roux-en-Y procedure and B12 anemia associated with gastric lymphoma was established in a July 2004 rating decision, which assigned a 20 percent rating under DC 7308 and a noncompensable rating under DC 7700 (for B12 anemia). Thereafter, in a June 2011 rating decision, the RO assigned a higher (40 percent) rating for status post gastrectomy, effective January 30, 2009, under DC 7308. The rating decision noted that the Veteran's red blood cell count and hemoglobin were normal and, therefore, he was not entitled to a separate evaluation for his anemia. Resolving doubt in favor of the Veteran, the Board finds that he meets the criteria for the maximum rating of 60 percent under DC 7308 for status post gastrectomy. Under DC 7308, a 40 percent disability rating is assigned for moderate postgastrectomy syndromes evidenced by less frequent episodes of epigastric disorders with characteristic mild circulatory symptoms after meals but with diarrhea and weight loss. A 60 percent disability rating is assigned for severe postgastrectomy syndromes associated with nausea, sweating, circulatory disturbance after meals, diarrhea, hypoglycemic symptoms, and weight loss with malnutrition and anemia. See 38 C.F.R. § 4.114, DC 7308. The Veteran underwent a status post total gastrectomy with partial liver resection secondary to gastric lymphoma in 1997. Due to the surgery, he developed B12/folate deficiency anemia. A September 2009 VA examination for diabetes mellitus type 2 showed no evidence of recurrent or metastatic lymphoma. The Veteran's B12 and folate anemias were stable. A year earlier, he was found to have significant iron deficiency anemia, but it had improved with monthly IV infusions of ferric gluconate without any residual disability. The Veteran reported daily fatigue related to his anemia. He denied any problems of nausea, vomiting, diarrhea, constipation, abdominal pain, bloating, hematemesis, hematochezia, melena, dumpling syndrome, weight loss or weakness. A May 2011 VA examination shows that the Veteran continued to have iron deficiency anemia and B12/folate deficiencies requiring supplementation. He reported diarrhea an average of twice a week, urgency to defecate three or four times per week, and abdominal pain three times per week, lasting up to one hour. There was no circulatory disturbance noted after meals, or hypoglycemic reactions reported. The Veteran stated that he can have nausea and/or vomiting with certain foods and notes some weight loss over time, remaining around 150 pounds in the last two years. The examiner noted that he weighed 170 pounds in 2005. The examiner diagnosed post gastrectomy syndrome, including early satiety, feelings of tenesmus, bloating, and variable other bowel habits, with continued iron, B12, and folate deficiencies, necessitating replacement intravenously in the case of iron and by injection in the case of cyanocobalamin (B12). The examiner stated that the Veteran was not anemic due to the iron deficiency anemia and that anemia was under control by treatment. A June 2012 VA examination shows signs or symptoms of anemia and weight loss. There was a scar related to the gastrectomy, but it was not painful, unstable or its area greater than 39 square cm. A May 2014 VA examination shows early satiety, occasional diarrhea, frequent small feedings, and weight loss (from 153 in 2009 to 140 at time of examination); it does not show recurrence of lymphoma. The Veteran still received parenteral B12 and iron regularly to treat his associated anemia. The examiner noted recurring episodes of symptoms that were not severe, with a frequency of four or more episodes per year and an average duration of less than a day. The examiner characterized the Veteran's post gastrectomy syndrome as moderate; less frequent episodes of epigastric disorders with characteristic mild circulatory symptoms after meals but with diarrhea and weight loss. Despite the characterization of the May 2014 examiner, the Veteran's disability picture, as described above, is found to most nearly approximate the criteria for a 60 percent rating under DC 7308. While the evidence shows that he had mild circulatory symptoms after meals and no hypoglycemic symptoms, the Board notes that his status post gastrectomy manifested as diarrhea, occasional nausea, and weight loss with anemia. The evidence also shows nausea, which is expressly contemplated under the 60 percent evaluation but not the 40 percent rating. The Board has considered whether a separate rating is warranted under DC 7700 for anemia. The medical evidence shows that the Veteran's hemoglobin has been over 10gm/100ml. As such, he is not entitled to a rating under DC 7700. All potentially applicable diagnostic codes have been considered, and the Veteran is not entitled to a rating in excess of the rating already assigned. See Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). Staged ratings have been established, but are not further warranted, as the Veteran's symptomatology remained relatively stable during the two periods. Any increases in severity were not sufficient for a higher rating for the reasons discussed above. Hart, 21 Vet. App. at 509-10. Extraschedular consideration is not warranted under 38 C.F.R. § 3.321(b)(1). His symptomatology, consisting of shortness of breath, is fully contemplated by the schedular rating criteria. Therefore, the rating schedule is adequate, it is not an exceptional or unusual disability picture, and referral for consideration of an extraschedular rating is not necessary. Thun v. Peake, 22 Vet. App. 111, 115-16 (2008). The Board notes that under Johnson v. McDonald, 762 F.3d 1362 (2014), a Veteran may be awarded an extraschedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the individual conditions fails to capture all the service-connected disabilities experienced. In this case, however, after applying the benefit of the doubt under of Mittleider v. West, 11 Vet. App. 181 (1998), there are no additional symptoms stemming from other service-connected disabilities that have not been attributed to the specific service-connected condition on appeal where there is any doubt as to their origin. Accordingly, this is not an exceptional circumstance in which extraschedular consideration may be required to compensate the Veteran for a disability that can be attributed only to the combined effect of multiple conditions. In sum, the preponderance of the evidence supports the maximum rating of 60 percent under DC 7308 for the Veteran's. A higher rating of 60 percent for the Veteran's status post gastrectomy is being granted based, in part, on application of the benefit-of-the-doubt doctrine TDIU A total disability rating may be assigned where the schedular rating is less than total, when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. 38 C.F.R. §§ 3.340, 4.16(a). This is so, provided that the unemployability is the result of a single service-connected disability ratable at 60 percent or more, or the result of two or more service-connected disabilities, where at least one disability is ratable at 40 percent or more and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). The Veteran is currently in receipt of a 50 percent rating for PTSD with depression; a 40 percent rating for status post gastrectomy; a 10 percent rating for diabetes mellitus type 2; and a noncompensable rating for gastric lymphoma. Since January 30, 2009, his combined rating is 70 percent. 38 C.F.R. § 4.25. The Veteran meets the criteria for consideration for entitlement to a TDIU on a schedular basis because the ratings satisfy the percentage requirements of 38 C.F.R. § 4.16(a). Even so, it must be found that he is unable to secure or follow a substantially gainful occupation as a result of his service-connected disabilities. Consequently, the Board must determine whether the Veteran's service-connected disabilities preclude him from engaging in substantially gainful employment (work that is more than marginal, which permits the individual to earn a "living wage"). Moore v. Derwinski, 1 Vet. App. 356 (1991). The fact that a Veteran may be unemployed or has difficulty obtaining employment is not determinative. The ultimate question is whether the Veteran, because of service-connected disability, is incapable of performing the physical and mental acts required by employment, not whether he can find employment. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). An inability to work due to advancing age may not be considered. 38 C.F.R. §§ 3.341(a), 4.19 (2014). In making its determination, VA considers such factors as the extent of the service-connected disability, and employment and educational background. See 38 C.F.R. §§ 3.340, 3.341, 4.16(b), 4.19. The evidence of record reflects that the Veteran's last employment was as a truck driver. From February 2005 to May 2011, he worked for five trucking companies. See May 2012 application for a TDIU. One of those companies reported that the Veteran was terminated due to poor performance. See VA Form 21-4192 (received in June 2012). During the May 2014 VA examination, the Veteran reported that he worked for American Motors from 1973 to 1990 in housekeeping. Since then, he has held many different jobs, mostly in truck driving. The longest job he held as a truck driver lasted one and half years, and he was typically terminated for accidents or having a bad attitude toward customers. In 2011, at the age of 62, he decided to retire and do odd jobs, which he continued to do up to then. The April 2015 informal hearing presentation indicates that the Veteran also worked in a paper mill factory and has only worked as truck driver and forklift driver. The record also reflects that the Veteran has a high school diploma and two years of post-secondary education, having attended a vocational school from 1966-1967 to earn a diploma in carpentry. See April 2015 informal hearing presentation. The Veteran has stated that his mental health disability is the biggest factor in his inability to maintain a job. See May 2012 statement in support of the TDIU claim. In this regard, he stated that he is tired all the time, has difficulty focusing, and explodes very easily at people. He indicated that he was fired from his last job due his anger issues and inability to follow the rules. He also stated that he has had a lot of driving accidents because he cannot concentrate or control his anger and irritability at the way other people drive. Thus, he believes that his mental health disability make it impossible for him to continue driving trucks. The Veteran has also stated that his gastrectomy residuals affect his capacity to work. See May 2012 statement in support of the TDIU claim. In this regard, he believes that his need to frequently go to the bathroom make it impossible for him to work in jobs other than truck driving, for which he might be qualified. The June 2012 VA examiner stated that given the Veteran's service-connected disabilities, excluding his mental health disability, he should be able to be employed in a full time sedentary position. With regard to the Veteran's diabetes mellitus type 2, the examiner indicated that it does not impact his ability to work. With regard to his service-connected gastrointestinal disabilities, the examiner stated that these limit the Veteran to sedentary work due to stamina issues. The examiner who performed the June 2012 VA psychiatric examination opined that the Veteran's mental health disability more likely than not did not prevent him from being employed in a sedentary capacity, given his multiple medical problems. The May 2014 VA examiner found that the Veteran diabetes mellitus type 2 does not limit his ability to work. With regard to the gastrointestinal disabilities, the examiner stated that the Veteran's post gastrectomy syndrome would require sedentary work with easy access to a bathroom. With regard to his mental health disability, the examiner stated that such disability would impose mild to moderate functional impairment on any type of employment due to his depression and PTSD symptoms, including interpersonal difficulties. The examiner noted that the Veteran's cognitive abilities remain intact. In considering the medical opinions above, the Board notes that the question of employability is ultimately a question of fact, and not a medical matter. Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013). After having reviewed the record and weighing the evidence both in support of and against the claim, the Board finds that the evidence is in relative equipoise as to whether the Veteran's service-connected disabilities render him unemployable for purposes of a TDIU. In this regard, the Board notes that the Veteran's capacity to work is especially impacted by his depressed mood, irritability, concentration issues, poor stamina, and occasional diarrhea. Although some evidence suggests that the Veteran might be able to do sedentary work, the Board finds that such option is not realistic given the Veteran's education level and previous work experience. In this regard, the Board notes that the Veteran's most recent work experience has been as a truck driver. This line of work is no longer an option for the Veteran given his concentration issues and history of driving accidents. Furthermore, there is no indication that he has ever performed work of a sedentary nature. Rather, the evidence shows that he worked a car manufacturing company for 17 years in housekeeping. More recently, he worked as a truck driver. He stated that he has done odd jobs since he retired from truck driving, but there is no indication that such jobs have been on a full-time basis or constituted substantially gainful employment. Additionally, his only vocational training is in carpentry. In light of the above, the Board finds the evidence to be in equipoise with respect to whether the service-connected disability at issue precludes him from obtaining and retaining substantially gainful employment. When reasonable doubt is resolved in the Veteran's favor, the Board finds that the Veteran's service-connected disabilities are as likely as not of such nature and severity as to prevent him from securing or following substantially gainful employment. See 38 U.S.C.A. § 5107(b) ; 38 C.F.R. §§ 3.102, 4.3 (2013); Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Therefore, entitlement to a TDIU is warranted. ORDER Service connection for tinnitus is denied. An initial rating of 70 percent for PTSD with depression is granted. A rating of 60 percent for post status gastrectomy with Roux-en-Y procedure and B12 anemia associated with gastric lymphoma is granted. Entitlement to a TDIU is granted. REMAND The Veteran is claiming service connection for a skin disability. The medical evidence shows diagnoses of polymorphous light eruption on the arms and seborrheic dermatitis on the face and neck. See September 2009 VA treatment record; see also VA treatment records from February 2009, March 2009, December 2009, and May 2010. The Veteran has stated that this condition began during service in Vietnam and that he has had it since then. See February 2009 VA treatment record. He is competent to report an in-service injury that is factual in nature, as well as his observable symptoms and history, including when he first perceived skin symptoms, and such reports must be considered. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Although service treatment records fail to show treatment for a skin condition during service, VA treatment records that predate the current claim show a record of skin abnormalities, such as a desquamative rash in the face and scalp. See December 2005 VA treatment record. Additionally, the Board notes that the Veteran's currently diagnosed skin disability, as described by his treatment providers, is seasonal in nature. While the Board acknowledges the absence of records for skin treatment prior to December 2005, it finds that such absence is not unreasonable or dispositive of the issue given the seasonal nature of the disability. In light of the above, the Board finds that a VA examination should be provided regarding the nature and etiology of the Veteran's current skin disability. Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a VA examination to determine the nature and etiology of any current skin disability. Review of the claims file should be noted in the examiner's report. The examiner should respond to the following: Is it at least as likely as not that a current skin disability was incurred in active service? The examiner must consider the Veteran's contention that a skin disability manifested, and has continued since, service in Vietnam. A complete rationale must be provided for any opinion offered. All lay and medical evidence should be considered. If the examiner cannot provide an opinion without resort to speculation, he/she should explain why that is the case and what, if any, additional evidence is necessary for an opinion. 2. If any benefit sought on appeal remains denied, issue a supplemental statement of the case. Then, return the case to the Board, if otherwise in order. (CONTINUED ON NEXT PAGE) The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). All claims remanded for additional development or other appropriate action must be handled expeditiously. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ____________________________________________ Eric S. Leboff Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs