Citation Nr: 1760583 Decision Date: 12/28/17 Archive Date: 01/02/18 DOCKET NO. 12-11 551A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Paul, Minnesota THE ISSUES 1. Entitlement to service connection for hypertension, to include as secondary to coronary artery disease. 2. Entitlement to an initial disability rating in excess of 30 percent for coronary artery disease (CAD) prior to January 2, 2014 and in excess of 60 percent thereafter. 3. Entitlement to an initial disability rating in excess of 10 percent for parenchymatous liver disease with hepatic steatosis prior to August 25, 2015. 4. Entitlement to a disability rating in excess of 30 percent for undifferentiated somatoform disorder prior to August 12, 2015, and in excess of 50 percent thereafter. 5. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) prior to August 25, 2015. REPRESENTATION Appellant represented by: Donald Fernstrom, Attorney WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Cheryl E. Handy, Counsel INTRODUCTION The Veteran served on active duty from February 1974 to March 1976. This matter is before the Board of Veterans' Appeals (Board) on appeal of rating decisions issued by a Department of Veterans Affairs (VA) Regional Office (RO). In May 2017, the Veteran appeared at a Board hearing before the undersigned Veterans Law Judge. A transcript of that hearing is in the claims file. The issue of entitlement to TDIU on an extraschedular basis prior to October 26, 2007, is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The Veteran's hypertension is not shown to have been caused or aggravated by his service-connected CAD. 2. From the date of claim in August 2004 through January 2, 2014, the Veteran's CAD was shown to be productive of symptoms no worse than symptom onset at 5 to 7 METs; left ventricular ejection fraction below 50 percent and chronic congestive heart failure were not shown. 3. After January 2, 2014, the Veteran's CAD has been characterized by symptoms of no worse than symptom onset at 3 to 5 METs; symptoms at less than 3 METs as a result of CAD alone, left ventricular ejection fraction below 50 percent, and chronic congestive heart failure have not been shown. 4. From the date of claim, the Veteran's liver disability has been shown to result in a disability picture that most nearly approximates daily fatigue, malaise, with substantial weight loss; the evidence is against a finding that the disability picture most nearly approximates that of near-constant symptoms. 5. Prior to August 12, 2015, the Veteran's undifferentiated somatoform disorder was shown to result in decreased work efficiency and intermittent periods of inability to perform occupational tasks; occupational and social impairment with reduced reliability and productivity was not shown. 6. As of August 12, 2015, the Veteran's undifferentiated somatoform disorder has been shown to result in symptoms of reduced reliability and productivity; occupational and social impairment with deficiencies in most areas has not been shown. 6. As of October 26, 2007, the Veteran's service-connected disabilities of parenchymatous liver disease, rated as 40 percent disabling; CAD, rated as 30 percent disabling; left ear tinnitus, rated as 10 percent disabling; and somatoform disorder, rated as 10 percent disabling, rendered him unable to obtain and maintain substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for service connection for hypertension have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304, 3.310 (2016). 2. The criteria for an initial disability rating in excess of 30 percent for CAD prior to January 2, 2014, and in excess of 60 percent thereafter have not been met. 38 U.S.C. §§ 1155, 5103, 5107 (2012); 38 C.F.R. §§ 3.321, 4.3, 4.7, 4.104, Diagnostic Code 7005 (2016). 3. The criteria for an initial disability rating of 60 percent, and no higher, for parenchymatous liver disease were met as of the date of claim. 38 U.S.C. §§ 1155, 5103, 5107 (2012); 38 C.F.R. §§ 3.321, 4.3, 4.7, 4.1115a, Diagnostic Code 7345 (2016). 4. The criteria for a disability rating in excess of 30 percent for undifferentiated somatoform disorder prior to August 12, 2015, and in excess of 50 percent thereafter have not been met. 38 U.S.C. §§ 1155, 5103, 5107 (2012); 38 C.F.R. §§ 3.321, 4.3, 4.7, 4.130, Diagnostic Code 9423 (2016). 5. The criteria for TDIU have been met as of October 26, 2007. 38 U.S.C. § 5107 (2012); 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.15, 4.16 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's Duties to Notify and Assist VA notified the Veteran of the evidence and information necessary to substantiate his claims in March 2006. Concerning the duty to assist, all identified, pertinent treatment records have been obtained and considered. These include records from the Social Security Administration (SSA). The Veteran has undergone multiple VA examinations related to the disabilities on appeal. See VA examinations from March 2006, February 2008, March 2008, March 2009, January 2012, March 2012, January 2014, August 2015, and September 2015. The Veteran has challenged the adequacy of the January 2012 VA examination for CAD. (See Statement in Support, 02/16/2012.) The Board notes that there have been two examinations since that date as well as a Disability Benefits Questionnaire (DBQ) submitted by the Veteran's physician. As such, any deficiencies in the January 2012 examination have been addressed. The Veteran has not submitted any other argument or indication that any other examinations were inadequate or that their findings do not reflect the current severity of the disability. In sum, there is no additional notice or assistance that would be reasonably likely to aid in substantiating the Veteran's issues on appeal. As such, the Board will proceed with consideration of the Veteran's appeal. Evidentiary Standards VA must give due consideration to all pertinent medical and lay evidence in a case where a Veteran is seeking service connection. 38 U.S.C. § 1154(a). Competency is a legal concept in determining whether medical or lay evidence may be considered, in other words, whether the evidence is admissible as distinguished from weight and credibility, a factual determination going to the probative value of the evidence, that is, does the evidence tend to prove a fact, once the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997). Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159. Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer a medical diagnosis, statement, or opinion. 38 C.F.R. § 3.159. The Board, as fact finder, must determine the probative value or weight of the admissible evidence. Washington v. Nicholson, 19 Vet. App. 362, 369 (2005) (citing Elkins v. Gober, 229 F.3d 1369, 1377 (Fed. Cir. 2000) ("Fact-finding in veterans cases is to be done by the Board")). When there is an approximate balance of positive and negative admissible evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the Veteran. 38 U.S.C. § 5107(b). Principles of Service Connection Generally, to establish a right to compensation for a present disability, a Veteran must show: (1) a present disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service, the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). All three elements must be established by competent and credible evidence in order that service connection may be granted. Under 38 C.F.R. § 3.303 (b), an alternative method of establishing the second and third Shedden element is through a demonstration of continuity of symptomatology. Barr v. Nicholson, 21 Vet. App. 303 (2007); see Savage v. Gober, 10 Vet. App. 488, 495-97 (1997); see also Clyburn v. West, 12 Vet. App. 296, 302 (1999). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Savage, 10 Vet. App. at 495-96; 38 C.F.R. § 3.303 (b). An award of service connection based solely on continuity of symptomatology only applies to the listed chronic disabilities in 38 C.F.R. § 3.309 (a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may be established on a secondary basis for a disability that is proximately due to, the result of, or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires (1) competent evidence (a medical diagnosis) of current chronic disability; (2) evidence of a service-connected disability; and (3) competent evidence that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310(a); see also Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). Facts and Analysis The Veteran seeks service connection for hypertension, which he has asserted is secondary to his service connected CAD. A March 2009 VA examination noted that the Veteran was diagnosed as a having a periodic spike of his blood pressure beginning in 2003. His diagnosis of hypertension was established at the same as his diagnosis of CAD, after he had a heart attack, and he was placed on antihypertensives in 2008. (See VA Exam, 03/16/2009, p. 2.) He reported that he was checking his blood pressure regularly two or three times per week with results of 130/85. He also reported having headaches which associated with his hypertension. At the VA examination in March 2012, the examiner noted the Veteran's diagnosis of hypertension in 2003 when he had a heart attack, with continuous medication thereafter. The examiner was asked to provide an opinion as to whether the Veteran's hypertension was the result of his CAD and stated that it was not. (See VA Exam, 03/01/2012, p. 13.) The examiner stated that while hypertension can cause CAD, the opposite was not true and the CAD was less likely than not the cause of the hypertension. In an addendum provided in June 2012, the examiner stated that the Veteran's hypertension was also not aggravated by his CAD because hypertension was caused by atherosclerosis of the peripheral arteries and CAD was caused by the narrowing of the coronary arteries, which are not peripheral arteries. (See VA Exam, 06/08/2012.) A DBQ completed in August 2015 noted that the Veteran had been diagnosed with hypertension in 2004 after elevated readings were noted beginning in 2003. He had been started on metoprolol and had been stable ever since. The provider did not offer an opinion as to the etiology of the Veteran's hypertension, but stated it did not affect his ability to work. At the Board hearing in May 2017, the Veteran's attorney stated that he believed that Dr. Bash had disagreed with the denial of service connection for hypertension as secondary to CAD. (See Hearing Transcript, 05/12/2017, p. 6.) The Veteran testified that his elevated blood pressure was first noticed after his heart attack and he began taking medication shortly thereafter. After considering all of the evidence of record, to include that discussed above, the Board finds that service connection for hypertension is not warranted. Specifically, the only competent medical evidence of record is that of the VA examination in 2012, which concluded that the Veteran's hypertension was neither caused nor aggravated by his CAD. The Veteran has provided no evidence to the contrary. A Veteran seeking benefits must provide some evidence to support the necessary elements of the claim, including causation; in this case, no such evidence has been provided. See Fagan v. Shinseki, 573 F.3d. 1282, 1286 (Fed. Cir. 2009). Moreover, the evidence fails to show, and the Veteran does not contend, that his current hypertension was incurred during active service. Continuity of symptomatology has not been shown. The Board acknowledges the Veteran's sincere belief that there is a relationship between his CAD and his hypertension, apparently based on the fact that the diagnosis was made at the time of his heart attack resulting from CAD. However, the Veteran is not shown to have any medical training or expertise and is therefore not competent to offer an opinion as to causation in this matter. While the Veteran's attorney stated at the hearing that he believed Dr. Bash felt that the Veteran's hypertension was caused by his CAD, the opinion provided by Dr. Bash in July 2008 pertained only to the question of service connection for CAD and did not include a discussion of hypertension. (See Medical Treatment Non-Government, 07/17/2008.) For these reasons, the Board finds that service connection for hypertension is not warranted based on the evidence. The preponderance of the evidence being against the claim, the benefit of the doubt standard does not apply here. 38 U.S.C. § 5107(b). Assigning Disability Ratings A disability rating is determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C. § 1155. Where there is a question as to which of two evaluations shall be applied, 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. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings." Hart v. Mansfield, 21 Vet. App. 505, 510 (2007). In this instance, staged ratings have been assigned for the Veteran's CAD and his liver disability. Facts and Analysis Coronary Artery Disease The Veteran's CAD, status post myocardial infarction (heart attack) is rated under Diagnostic Code 7006, with a 30 percent disability rating assigned from March 2004 to January 2014. A 60 percent disability rating has been assigned as of August 2015. Coronary artery disease may also be rated under Diagnostic Code 7005, which lists precisely the same criteria. 38 C.F.R. § 4.104. Diagnostic Code 7006 provides for a 100 percent disability rating for the three months following myocardial infarction that is documented by laboratory tests, a 100 percent rating is assigned. Thereafter, a history of documented myocardial infarction resulting in workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray, is rated 30 percent disabling. A history of documented myocardial infarction resulting in more than one episode of acute congestive heart failure in the past year, or; workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent, is rated 60 percent disabling. A history of documented myocardial infarction resulting in chronic congestive heart failure, or; workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent, is rated 100 percent disabling. 38 C.F.R. § 4.104. For rating diseases of the heart, one MET is the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for rating, and a laboratory determination of METs by exercise testing cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. 38 C.F.R. § 4.104, Note 2. The Veteran filed his claim of service connection for CAD in March 2004 and that is the effective date of the grant of disability; at present he is rated at 30 percent Prior to January 2, 2014 and 60 percent therefrom. The Veteran has reported having a heart attack in December 2003. A May 2008 cardiac study showed that the Veteran had a left ventricular ejection fraction of 65 percent. (See Medical Treatment, 09/25/2008, p. 1.) Additional testing at the same time showed METs of 8.1. (p. 4.) At the March 2009 VA examination, the Veteran reported that he was able to proceed through light physical exercise and could walk three or four blocks without shortness of breath, chest pain, and palpitations. (See VA Exam, 03/16/2009, p. 3.) A recent EKG was normal. The examiner stated that the Veteran's current METs level was 7 to 8. At the January 2012 VA examination, the Veteran had a history of normal EKG in November 2011, with the most recent myocardial perfusion test being from May 2008. (See VA Exam, 01/04/2012, pp. 11-13.) At that time his left ventricular ejection fraction was 65 percent and METs of 8. Based on an interview, the Veteran's METs were estimated as 5 to 7, which was consistent with walking one flight of stairs, golfing without a cart, mowing with a push mower, and digging. It was felt that the interview based METs test was the most accurate reflection of his current cardiac function. At the January 2014 VA examination, the Veteran was noted to have undergone a myocardial perfusion study in July 2012 as a result of chest pain, and the results were similar to those at that time of his heart attack. (See VA Exam, 01/02/2014, p. 2.) He reported experiencing decreased stamina and poor circulation, as well as being more easily fatigued. His ejection fraction was shown as 64 percent. A DBQ completed in August 2015 noted the Veteran's heart attack in 2003 and his hospitalization in 2005 for unstable angina. (See C&P Exam, 08/25/2015, p. 10.) The Veteran's heart condition had been stable since then and he took metoprolol and aspirin for his symptoms. He reported fatigue, shortness of breath, dizziness, and chest pain with exertion. The provider noted evidence of cardiac hypertrophy on an echocardiogram in August 2015, with a left ventricular ejection fraction of 55 to 60 percent. Interview based METs were estimated at 1-3, based on symptoms including dyspnea, fatigue, and dizziness with exertion. This level was consistent with activities such as eating, dressing, taking a shower, and walking one to two blocks at a slow rate. The Veteran's METs were limited by liver disease, with the heart condition accounting for only 50 percent of the score given. A VA medical opinion obtained in September 2015 found that the best measurement for the Veteran's METs was to be reached using the left ventricular ejection fraction rather than an interview-based estimate. (See C&P Exam, 09/30/2015, p. 2.) The Veteran's cardiac condition had been stable since his heart attack in 2003 and had remained quite good. The Veteran was not felt to be a good historian as shown in treatment notes from July 2015. The Veteran's left ventricular ejection fraction was 55 to 60 percent; his echocardiogram was stable between 2012 and 2015. The examiner stated that any limitations to the Veteran's capacity were related to other non-cardiac conditions. After considering all of the evidence of record, to include that set forth above, the Board finds that a disability rating higher than 30 percent for CAD is not warranted prior to January 2, 2014. Specifically, the evidence shows that prior to that date the Veteran's METs were at 5 to 7, he had a normal EKG, and his left ventricular ejection fraction was over 50 percent. All of these symptoms are consistent with a disability rating no higher than 30 percent. The January 2012 VA examination showed interview based METs of 5 to 7; the interview based test was felt to be the most accurate reflection of his current cardiac function. This result warrants assignment of a 30 percent disability rating, but does not support a rating in excess of 30 percent. The DBQ from August 2015 also utilized an interview-based test, which estimated the METs as 1 to 3, but indicated that only half of that result was attributable to the Veteran's cardiac disability; the other half was due to his liver disability. The Board notes that the VA medical opinion in September 2015 had indicated that the Veteran's left ventricular ejection fraction was a better measurement for his cardiac functioning than the interview-based METs test. The opinion also noted that the Veteran is not a good historian and many indications of cardiac function have been stable since his heart attack. However, this opinion does not address the acute exacerbation of the Veteran's angina that resulted in hospitalization. Nor does it address the fact that the January 2012 examination used an ejection fraction from May 2008 with no new exercise based stress test, which result in the interview-based METs score being the only contemporaneous finding. For this reason, the Board will afford the most weight to the interview-based METs score from the January 2012 VA examination. The interview-based METs score from the August 2015 DBQ must be considered along with the fact that only half of the score is attributable to the Veteran's heart problems. After the January 2012 VA examination, there is no evidence to support the next-higher disability rating until the January 2014 VA examination, which was the basis for the award of a 60 percent rating for CAD. Specifically, the discussion of the interview-based METs score lower than 3 detailed that only 50 percent of that score was due to the Veteran's heart condition; as such, the finding of METs less than 3 cannot be said to warrant a 100 percent disability rating. The Veteran's left ventricular ejection fraction has never been below 30 percent. For these reasons, the Board finds that the criteria for a 100 percent disability rating have not been met. Throughout the appeals period, the Veteran has repeatedly reported angina or pain in his chest region on a frequent basis. No diagnosis of angina is of record, although the Veteran has been prescribed nitroglycerin tables and got good symptom relief from aspirin. The Board notes that there is no specific diagnostic code for angina, because the focus of the rating criteria is on the functional impact of symptoms such as angina, as covered in the applicable rating criteria here. Angina is listed as one of the considerations in computing METs, along with dyspnea and fatigue. Liver The Veteran's parenchymatous liver disease is rated under Diagnostic Code 7345, with a 10 percent disability rating provided for the period from March 2004 to August 2015. A 100 percent disability rating has been assigned as of August 25, 2015. Under Diagnostic Code 7345, chronic liver disease with intermittent fatigue, malaise, and anorexia, or; incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain) having a total duration of at least one week, but less than two weeks, during the past 12-month period, is rated 10 percent disabling. Chronic liver disease with daily fatigue, malaise, and anorexia (without weight loss or hepatomegaly), requiring dietary restriction or continuous medication, or; incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain) having a total duration of at least two weeks, but less than four weeks, during the past 12-month period, is rated 20 percent disabling. Chronic liver disease with daily fatigue, malaise, and anorexia, with minor weight loss and hepatomegaly, or; incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain) having a total duration of at least four weeks, but less than six weeks, during the past 12-month period, is rated 40 percent disabling. Chronic liver disease with daily fatigue, malaise, and anorexia, with substantial weight loss (or other indication of malnutrition), and hepatomegaly, or; incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain) having a total duration of at least six weeks during the past 12- month period, but not occurring constantly, is rated 60 percent disabling. Chronic liver disease with near-constant debilitating symptoms (such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain), is rated 100 percent disabling. 38 C.F.R. § 4.114. Note (2) to Diagnostic Code 7345 provides that, for purposes of rating conditions under Diagnostic Code 7345, "incapacitating episode" means a period of acute signs and symptoms severe enough to require bed rest and treatment by a physician. 38 C.F.R. § 4.114. At a treatment visit in June 2005, the Veteran reported that he frequently used marijuana to deal with his nausea, which he believed was due to his liver problems. (See Medical Treatment, 02/14/2006, p. 10.) He reported issues with nausea and frequent vomiting after meals. At a VA examination in March 2006, the Veteran reported a diagnosis of parenchymal liver disease. (See VA Exam, 03/09/2006, p. 2.) He had nausea three or four times per week, but denied vomiting. He complained of diffuse abdominal pain, mostly in the right upper quadrant, which increased with food consumption. He reported liquid stool and denied constipation. He had never been admitted to any medical institution for treatment. A CT scan from April 2005 showed diffuse low attenuation of the liver consistent with fatty infiltration. On examination, the Veteran's abdomen was distended, but there was no organomegaly or fluid accumulation. Palpation of the right upper quadrant was moderately painful. In his Notice of Disagreement submitted in July 2006, the Veteran stated that he had all of the symptoms described in the criteria for a 30 percent disability rating. (See NOD, 07/12/2006, p. 1.) He specifically reported weakness, abdominal pain, malaise and portal hypertension. Lab reports were also abnormal, including elevated glucose, ALT liver enzymes, high cholesterol, and triglycerides. On his VA Form 9 the Veteran listed the following symptoms of liver disease: right quadrant pain, nausea, and vomiting. (See Form 9, 11/08/2006, p. 4.) An October 2007 report showed a large prominent spleen with increased surface vasculature. He had lost weight, going from 204 pounds in March 2006 to 189 in October 2006. He had daily fatigue, malaise, weight loss without change in eating habits or activity levels, nausea and vomiting three to four times per week, constant debilitating right quadrant pain, and incapacitating episodes of nausea and vomiting three to four times per week. He described his incapacitating episodes as requiring him to lie down and prepare to vomit. At the VA examination in February 2008, the Veteran described his symptoms as periodic nausea, vomiting, and intermittent diarrhea or constipation. (See VA Exam, 02/28/2008, p. 3.) The examiner stated that blood tests had shown that liver function status was normal since September 2006 and on testing in February 2007. At treatment in April 2008 the Veteran had complaints of continuing liver pain and stated that he had been vomiting daily for 30 years. (See Medical Treatment, 09/25/2008, p. 7.) He also had been having chronic right upper quadrant pain for the past 30 years, which was more or less continuous. A February 2009 dental treatment visit noted that the Veteran's primary problem with his teeth was that he vomited with almost all meals and had the dental changes of bulimia. (See Medical Treatment, 10/29/2014, p. 34.) At the January 2012 VA examination, the Veteran reported that he is frequently nauseated and had frequent diarrhea. (See VA Exam, 01/04/2012, p. 18.) He did not have jaundice or leg swelling. A CT of the liver in April 2007 showed a normal appearance of the liver and spleen, with no demonstrated biliary obstruction. At treatment in October 2012 the Veteran wanted to address problems related to over 30 years of vomiting since he left military service. (See Medical Treatment, 07/14/2015, p. 3.) He stated that he was tired of not feeling well and reported increased weight loss, muscle and joint tenderness, numbness in hand and feet, dyspnea on exertion, malaise, and fatigue. He denied having diarrhea, constipation, abdominal pain, cramping, difficulty swallowing, sore throat, heart burn and indigestion, increased thirst, and hemaoptysis. The DBQ completed in August 2015 noted that the Veteran had sharp stabbing pain in the right upper quadrant that occurred every day. (See C&P Exam, 08/25/2015, p. 24.) He ate only once a day and had no appetite. He reported having nausea and vomiting every day. The provider described the Veteran's fatigue, malaise, and right upper quadrant pain as near constant and debilitating. His weight was listed as 170 pounds. At the Board hearing in May 2017 the Veteran testified that he got nauseated frequently and threw up frequently. (See Hearing Transcript, 05/12/2017, p. 10.) He had stabbing pain in his liver which was sometimes sharp and sometimes a dull ache. It was continuous, as was the nausea and vomiting. After considering all of the evidence of record, to include that set forth above, the Board finds that the Veteran's disability picture has most nearly approximated that of a 60 percent disability rating from the date of his claim. The Veteran has reported frequent, sometimes daily, vomiting, along with continual nausea and right upper quadrant pain. He has also reported constant fatigue and malaise. These symptoms are supported by the preponderance of the medical evidence set forth above, although there is some variation in the reports of his frequent nausea and vomiting. However, the Board finds the dental treatment record of February 2009 describing the dental changes associated with regular vomiting over many years to be significant. Moreover, there is a showing of substantial weight loss. In March 2006 his weight was 204 pounds. This dropped to 189 pounds in October 2006. By the time of the August 2015 DBQ his weight was listed as 170 and he was noted to be eating only once daily. His "baseline" weight noted in that report was 220 pounds, indicating a drop of 50 pounds. For the above reasons, a 60 percent evaluation is warranted from the date of claim. The record fails to substantiate a disability picture most nearly approximating the 100 percent rating. While severe, the evidence overall falls short of demonstrating near-constant symptoms. For example, the August 2015 DBQ indicated daily but not near-constant anorexia, nausea, and vomiting. Somatoform Disorder The Veteran is currently service connection for undifferentiated somatoform disorder. He filed a claim for an increased disability rating in October 2011, after which time a 30 percent disability rating has been assigned, with a 50 percent rating assigned as of August 12, 2015. Ratings for somatoform disorder are assigned under the General Rating Formula for Mental Disorders at 38 C.F.R. § 4.130, which provides the following ratings for psychiatric disabilities: The General Rating Formula for Mental Disorders at 38 C.F.R. § 4.130 provides the following ratings for psychiatric disabilities: Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events), is assigned a 30 percent rating. Occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships, is assigned a 50 percent rating. 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 worklike setting); inability to establish and maintain effective relationships, is assigned a 70 percent rating. 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, is assigned a 100 percent rating. 38 C.F.R. § 4.130. At the VA examination in January 2012 the examiner noted the diagnosis of undifferentiated somatoform disorder, which did not appear to result in any greater limitation of functioning than at the prior examination in 2008. (See VA Exam, 01/04/2012, p. 30.) The examiner noted that disability resulted in occupational and social impairment due to mild or transient symptoms that decreased work efficiency and ability to perform occupational tasks only during periods of significant stress. It did not cause significant social impairment other than missing social gatherings and causing preoccupation with his health. There were no obvious occupational impairments, other than problem intermittent absences from work. The examiner did note that the Veteran had difficulty in adapting to stressful circumstances based on his report that he got "mad" when he was stressed. At the August 2015 VA examination, the Veteran reported that he had been divorced for over twenty years and was not in any relationship. (See C&P Exam, 08/12/2015, p. 3.) He did not have much of a relationship with his siblings or most of his children, had few friends, and did not socialize much. He reported infrequent use of alcohol, but used marijuana regularly to help him sleep. The examiner listed the Veteran's symptoms as depressed mood, anxiety, chronic sleep impairment, disturbances of motivation and mood, and difficulty adapting to stressful circumstances. The Veteran's thought processes and concentration were good and he was able to attend to his activities of daily living. The VA examiner described the Veteran's disability picture as one of occupational and social impairment due to mild or transient symptoms which decreased work efficiency and ability to perform occupational tasks only during periods of significant stress. After consideration of all of the evidence of record, to include that discussed above, the Board finds that the Veteran's disability picture related to his mental health disability does not warrant an increase above percent prior to the date of his increased rating claim in October 2011. Specifically, a higher disability rating would require evidence of occupational and social impairment with reduced reliability and productivity. However, the January 2012 examination described the Veteran's social impairment as less than significant, amounting to missing social gatherings and preoccupation with his health. His level of occupational impairment was described as likely to result in intermittent absences from work, as well as difficulty in adapting to stressful situations. This is consistent with decreased work efficiency and intermittent periods of inability to perform occupational tasks, the rating criteria for the assigned 30 percent disability rating. As of August 12, 2015, the Veteran's disabilities were shown to result in reduced reliability and productivity, but did not amount to demonstrated deficiencies in most areas as a result of his somatoform disorder and resulting fixation on his physical health, particularly his liver. As such, the 50 percent disability rating assigned as of this date was appropriate and the disability level for a 70 percent disability rating had not been shown. The Veteran reported having a limited social life, maintaining relationships with only a few of his children, and he was not currently employed as a result of his physical health. However, he was able to perform the activities of daily living and to care for himself and his thought processes and concentration were good. While he had "few" friends he was not noted as being friendless; indeed, even at the August 2015 examination it was noted that he had friends stay at his camper. While the Veteran had some depressed mood and anxiety, he did not have deficiencies in judgment, nor had he shown illogical speech, difficulty functioning independently, appropriately, and effectively, or impaired impulse control. As such, the Board finds that the criteria for a 70 percent disability rating for somatoform disorder have not been met or approximated here. Entitlement to TDIU Total disability ratings for compensation may be assigned, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that, if there is only one such disability, this disability shall be ratable at 60 percent or more, and that, if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). The Veteran seeks entitlement to TDIU prior to the date of his 100 percent disability award for parenchymatous liver disease on August 25, 2015. When the decisions set forth above are effectuated, the Veteran's combined disability rating as of October 26, 2007 will be at least 70 percent throughout the rating period on appeal. As such, the schedular criteria for TDIU will be met as of that date. (For the question of entitlement to TDIU on an extraschedular basis prior to that date, see the Remand portion below.) The question that remains, then, is whether the evidence establishes that the Veteran was unable to obtain and maintain substantially gainful employment as of that date as a result of his service-connected disabilities. The disabilities in question would be CAD, rated as 60 percent disabling; parenchymatous liver disease, rated as 60 percent disabling; left ear tinnitus, rated as 10 percent disabling; and undifferentiated somatoform disorder, rated as 10 percent disabling. A July 2005 mental health visit noted that the Veteran was unemployed and was not interested in pursuing further employment even though he was in financial distress. (See Medical Treatment, 02/14/2006, p. 12.) In a statement submitted in November 2006, the Veteran indicated that he had last worked as a truck driver from May 2004 to July 2004, with prior work for the same company in January 2001 to December 2003. (See VA 21-8940, 11/21/2006.) The Veteran stated that he could no longer drive a truck because of his heart and liver disabilities. The Board notes that the Veteran's duties in service included driving a truck and this profession seems to account for the majority of his occupational experience. At the March 2008 VA examination, the Veteran reported that he was not working because of his heart disability, particularly his angina. (See VA Exam, 03/31/2008, p. 9.) He stated that a VA physician had told him he was unable to work because of the 70 percent scar tissue in his heart and his recurrent chest pain. The May 2008 letter from Dr. Bash stated that the Veteran was totally disabled and unable to maintain or obtain gainful employment as a result of his service-connected medical problems and should be awarded TDIU. (See Medical Treatment, 07/17/2008, p. 8.) In a statement submitted in February 2012, the Veteran asserted that VA had already admitted that he was unemployable due to his heart disability. (See Statement in Support, 02/16/2012, p. 1.) Specifically, he asserted that in 2007 he had been denied TDIU because his unemployability was due to his heart, which was not at that time a service-connected disability. At the August 2015 VA mental health examination, the Veteran reported that he had last worked in 2004. (See C&P Exam, 08/12/2015, p. 4.) He had stopped driving truck after he had a heart attack because he could not handle the stress. At the May 2017 Board hearing, the Veteran's attorney specified that the TDIU claim was based on CAD, which he felt warranted a 100 percent disability from the date of the Veteran's heart attack in 2003, and on his mental health issues. (See Hearing Transcript, 05/12/2017, p. 3.) The Veteran had described having incidents while driving truck where he was approaching a bridge or a downhill slope and became terrified that he would lose consciousness. It was these incidents that had prompted him to stop driving a truck. Alternatively, the attorney asserted that the Veteran was entitled to TDIU back to the date of Dr. Bash's report in May 2008. In light of all of the evidence of record, to include that set forth above, the Board finds that TDIU is warranted throughout the rating period on appeal. Specifically, the opinion of Dr. Bash in May 2008 supports such conclusion that the Veteran's CAD rendered him unemployable at that time. Since the Veteran was also suffering from a liver disability which resulted in nausea, vomiting, incapacitating episodes, and pain, as well as tinnitus and a mental health disability, the overall disability picture is of an individual who was unemployable as a result of service-connected disabilities. ORDER Entitlement to service connection for hypertension, to include as secondary to CAD, is denied. Entitlement to an initial disability rating in excess of 30 percent for CAD prior to January 2, 2014 and in excess of 60 percent thereafter, is denied. Entitlement to an initial disability rating of 60 percent, and no higher, for parenchymatous liver disease from March 2004 is granted. Entitlement to a disability rating higher than 30 percent for undifferentiated somatoform disorder prior to August 12, 2015, is denied. Entitlement to a disability rating higher than 50 percent for undifferentiated somatoform disorder after August 12, 2015, is denied. Entitlement to TDIU is granted. ______________________________________________ Eric S. Leboff Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs