Citation Nr: 1701264 Decision Date: 01/18/17 Archive Date: 01/27/17 DOCKET NO. 11-30 700 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to service connection for hypertension. 2. Entitlement to service connection for a right arm disability. 3. Entitlement to service connection for an acquired psychiatric disorder, specifically claimed as posttraumatic stress disorder (PTSD). 4. Entitlement to a rating in excess of 30 percent for cardiomegaly. 5. Entitlement to a compensable rating for pseudofolliculitis barbae. 6. Entitlement to a total disability rating due to individual unemployability. 7. Entitlement to a combined evaluation greater than 30 percent effective April 16, 2009, and greater than 40 percent effective May 19, 2010. 8. Entitlement to an earlier effective date for the grant of service connection for cardiomegaly. 9. Entitlement to a rating in excess of 20 percent for a right shoulder disability. 10. Entitlement to service connection for a bilateral eye disability, to include cataracts. 11. Entitlement to service connection for a chronic headache disability. 12. Entitlement to service connection for a disability manifested by dizziness. 13. Entitlement to service connection for left ear hearing loss. 14. Entitlement to service connection for a respiratory disability. REPRESENTATION Veteran represented by: South Carolina Office of Veterans Affairs ATTORNEY FOR THE BOARD J. Ivey-Crickenberger, Associate Counsel INTRODUCTION The Veteran served on active duty in the United States Army from May 1971 to May 1973. This matter comes before the Board of Veterans' Appeals (Board) on appeal from numerous rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO). Jurisdiction resides with the RO in Columbia, South Carolina. A service connection claim for a psychiatric disability encompasses claims for all acquired psychiatric disorders that are reasonably raised by the record. Clemons v. Shinseki, 23 Vet. App. 1 (2009). Thus, the Board has recharacterized the claim as reflected on the cover page. The Veteran was afforded an in-person hearing before a Decision Review Officer in June 2015. The hearing transcript is associated with the record. The issue of entitlement to service connection for a back disability has been raised by the record in a December 2014 informal claim, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. 38 C.F.R. § 19.9(b) (2015). This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2015). 38 U.S.C.A. § 7107(a)(2) (West 2014). The issues of entitlement to service connection for hypertension; entitlement to service connection for PTSD; entitlement to TDIU; entitlement to a combined evaluation greater than 30 percent effective April 16, 2009, and greater than 40 percent effective May 19, 2010; entitlement to an earlier effective date for the grant of service connection for cardiomegaly; entitlement to a rating in excess of 20 percent for a right shoulder disability; entitlement to service connection for a bilateral eye disability, to include cataracts; entitlement to service connection for a chronic headache disability; entitlement to service connection for a disability manifested by dizziness; entitlement to service connection for left ear hearing loss; and entitlement to service connection for a respiratory disability are addressed in the REMAND portion of the decision below and are REMANDED to the AOJ. FINDINGS OF FACT 1. The preponderance of the evidence shows the Veteran has no current right arm disability. 2. The evidence is at least in equipoise as to whether the Veteran's cardiomegaly met the criteria for a 60 percent evaluation as of the date of claim until August 11, 2009. 3. As of August 12, 2009, the most probative evidence of record reflects that the Veteran's cardiomegaly has been manifested by, and best evaluated based on, left ventricular dysfunction with an ejection fraction of greater than 55 percent. 4. As of September 6, 2012, the Veteran's pseudofolliculitis barbae has affected less than five percent of his entire body, less than five percent of exposed areas, and has been treated by topical corticosteroid therapy on a constant or near constant basis. CONCLUSIONS OF LAW 1. The criteria for a 60 percent rating, and no more, for pseudofolliculitis barbae have been met as of September 6, 2012. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. § 4.118, Diagnostic Code 7806 (2015); Johnson v. McDonald, 27 Vet. App. 497 (2016). 2. Affording the Veteran the benefit of the doubt, the criteria for a rating of 60 percent, but no greater, for cardiomegaly have been met from the date of claim until August 11, 2009. 38 U.S.C.A. § 1155, 5107 (West 2014); 38 C.F.R. § 4.104, Diagnostic Code 7020 (2015). 3. As of August 12, 2009, the criteria for a rating of 30 percent, but no greater, for cardiomegaly have been met. 38 U.S.C.A. § 1155, 5107 (West 2014); 38 C.F.R. § 4.104, Diagnostic Code 7020 (2015). 4. The criteria for service connection for a right arm disability have not been met. 38 U.S.C.A. §§ 1110, 1154(a), 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.303 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Principles of Service Connection Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (table decision). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his or her current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if: (1) the layperson is competent to identify the medical condition; (2) the layperson is reporting a contemporaneous medical diagnosis; or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d at 1376-77. The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the Federal Circuit, citing its decision in Madden, recognized that the Board had an inherent fact-finding ability. Id. at 1076; see also 38 C.F.R. § 7104(a) (2015). Moreover, the Court has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing, if relevant. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table decision). Facts and Discussion - Right Arm Disability The evidence of record does not show a current right arm disability. In his June 2015 Decision Review Officer (DRO) hearing at the RO, the Veteran reported that he fell while playing basketball during service injuring his right arm. The Board observes that the Veteran injured his right shoulder during this incident and is currently seeking a higher evaluation for his right shoulder disability. The DRO asked the Veteran if any physician had given the Veteran a separate diagnosis for his right upper extremity disability in addition to his right shoulder. The Veteran answered in the affirmative, but provided no meaningful information in his response. The Board observes that there is no medical evidence of record showing the Veteran has a right arm disability. The very limited amount of lay evidence of record in this regard does little to support the claim. For instance, the Veteran reported in the DRO hearing that his "right arm" disability was manifested by difficulty raising his arm and not any problem with the function of his arm, such as limited motion or pain at the elbow or wrist, for example. The Board finds that the most probative evidence of record shows that the Veteran does not have a right arm disability in addition to his right shoulder disability. The Board notes that the existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C.A. § 1131; see Degmetich v. Brown, 104 F.3d 1328, 1332 (1997) (holding that interpretation of sections 1110 and 1131 of the statute as requiring the existence of a present disability for VA compensation purposes cannot be considered arbitrary). Evidence must show that the Veteran currently has the disability for which benefits are being claimed. In the absence of a current disability, the analysis ends, and the claim for service connection for a right arm disability distinct from the service-connected right shoulder disability cannot be granted. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Principles for Rating Disabilities Disability ratings are determined by applying a schedule of ratings (Rating Schedule) that is based on average impairment of earning capacity. Separate diagnostic codes (DCs) identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history, and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of a veteran working or seeking work. 38 C.F.R. § 4.2. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. To evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Assignment of "staged" ratings is appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Rating Criteria and Discussion - Heart Disability The Board notes that, as there is no specific diagnostic code for cardiomegaly, the Veteran's cardiomegaly has been rated by analogy under DC 7020, cardiomyopathy. The symptoms listed under DC 7020 include, in part, dyspnea, fatigue, dizziness, syncope, and left ventricular ejection fraction dysfunction. The Board finds that DC 7020 most nearly approximates the Veteran's symptoms. The Veteran's service-connected heart disability is currently rated as 30 percent disabling under DC 7099-7020 for the entire appeal period. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. Unlisted disabilities requiring rating by analogy will be coded by the numbers of the most closely related body part and 99. 38 C.F.R. § 4.27 (2015). The hyphenated diagnostic code in this case indicates that an unlisted organic disease of the cardiovascular system, under Diagnostic Code 7099, was the service-connected disorder, while the residual condition (to which the Veteran's service-connected heart disability is rated by analogy) is cardiomyopathy, which is evaluated under DC 7020. 38 C.F.R. § 4.104. Under Diagnostic Code 7020, a 100 percent rating is to be assigned for symptomatology more nearly approximating chronic congestive heart failure; a workload of three METs or less results in dyspnea, fatigue, angina, dizziness, or syncope; or left ventricular dysfunction with an ejection fraction of less than 30 percent. A 60 percent rating is to be assigned for symptomatology more nearly approximating more than one episode of acute congestive heart failure in the past year; or a workload of greater than three METs but not greater than five METs results in dyspnea, fatigue, angina, dizziness, or syncope; or left ventricular dysfunction with an ejection fraction of 30 to 50 percent. A 30 percent rating is appropriate for symptomatology more nearly approximating a workload of greater than five METs but not greater than seven METs results in dyspnea, fatigue, angina, dizziness, or syncope; or evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. The evidence reflects the Veteran had a Cardiolite rest test and a treadmill stress test in February 2009. The Cardiolite study was normal; however, the left ventricular ejection fraction was calculated at 49 percent. The stress test results reflect that the Veteran experienced no stress-induced chest pain at the maximum heart rate achieved. He was on the treadmill for over six minutes using the accelerated Bruce protocol and he achieved 10.30 METs. The Veteran had an echocardiogram study of his heart in six months later in August 2009; the provider indicated that the left ventricular ejection fraction was estimated as greater than 55 percent. The provider also noted mild concentric left ventricular hypertrophy, trace mitral regurgitation, and trace tricuspid regurgitation. A VA cardiology treatment note from November 2010 reflects that the Veteran complained of chest pain and exhaustion. The Veteran also reported that he was told at the time of discharge from service that his heart was slightly enlarged. He complained of tightness in his chest, precipitated by walking, with a pain level of eight out of ten in severity. The tightness did not radiate to the left upper limb or the neck. The Veteran also reported dyspnea, occasional dizziness, and becoming easily exhaustible. The provider noted that the Veteran's February 2009 ETT Cardiolite stress test was normal; the Veteran had exercised on a treadmill on an accelerated Bruce protocol for over six minutes, with a workload of 10.3 METs, and there was no stress-induced pain at the maximum heart rate achieved. The physician noted that an electrocardiogram from that date showed non-diagnostic ST and T wave abnormality. The diagnostic impression was left ventricular hypertrophy and chest pain of unknown etiology; there was no cardiomegaly. The provider stated that he did not believe the Veteran's easy fatigability was related to his cardiac condition. An x-ray from February 2014 reflects a finding of mild cardiomegaly. The Veteran received a VA heart examination in February 2014. The Veteran reported no history of myocardial infarction, no congestive heart failure, no cardiac arrhythmia, and no hospitalizations for treatment of a heart condition. There was evidence of cardiac hypertrophy. The provider cited the greater than 55 percent ejection from August 2009; however the February 2009 results of 49 percent were not noted or discussed. The examiner indicated that an exercise stress test was not administered. An interview-based METs test reflects the Veteran reported fatigue and dizziness at the one-to-three METs level, which is consistent with activities such as eating, dressing, taking a shower, or slow walking for one-to-two blocks. The examiner further noted, however, that the Veteran's METs level limitation was solely due to his heart condition, was due to multiple factors including osteoarthritis and back pain, and it was not possible to accurately estimate the percentage. Thereafter, the RO requested an addendum medical opinion from the VA heart examiner. Specifically, the examiner was asked to opine as to which results were the best indicator of the current severity of his heart disability: the left ventricular ejection fraction of greater than 55 percent or the interview-based METs estimate in the one-to-three level. The addendum, dated July 2014, reflects that the left ventricular ejection fraction of greater than 55 percent was the best indicator of the Veteran's cardiac disability. Although the evidence is somewhat contradictory in that the Veterans METs levels and contemporaneous left ventricular ejection fraction support different evaluations on numerous occasions, the Board finds that a staged rating is appropriate in this case. An evaluation of 60 percent, but no greater, is warranted from the date of claim until August 11, 2009. The Board comes to this conclusion based on the Veteran's February 2009 left ventricular ejection fraction of 49 percent, even though the Veteran's exercise-based METs level would not warrant this higher rating. The Board is granting this stage of increased evaluation based partially on the July 2014 VA examination addendum which reflects that the left ventricular ejection fraction was the best indicator of the Veteran's cardiac disability. As of August 12, 2009, a lower evaluation of 30 percent is warranted as the diagnostic tests showed a left ventricular ejection fraction of greater than 55 percent. Again, this is based partially on the July 2014 VA examination addendum which reflects that the left ventricular ejection fraction was the best indicator of the Veteran's cardiac disability. The Board finds that a 60 percent evaluation is not warranted for this period for several reasons. First, the February 2014 examiner indicated that the interview-based METs estimate was at least partially related to the Veteran's osteoarthritis and low back disabilities. Second, the examiner stated that it was impossible to accurately estimate METs based on an interview alone; third, the examiner indicated that the left ventricular ejection fraction was the best indicator of his disability. In addition, the Board observes that although the Veteran had a 49 percent left ventricular ejection fraction in February 2009, he was able to achieve 10.30 METs in a contemporaneous exercise-based test. Moreover, his left ventricular ejection fraction was estimated at greater than 55 percent only six months later. As such, the preponderance of the evidence reflects that a 30 percent rating, but not greater, is warranted for the period beginning on August 12, 2009. The Board also finds that the criteria for a 100 percent evaluation have not been met at any point during the appeal period for the reasons discussed in the previous paragraph and also because the record does not show evidence of chronic congestive heart failure or left ventricular dysfunction with an ejection fraction of less than 30 percent. In sum, after weighing the evidence of record and affording the Veteran the benefit of the doubt, a 60 percent evaluation but no greater is warranted for the Veteran's heart condition from the date of claim until August 11, 2009 and a 30 percent evaluation is warranted thereafter. Rating Criteria and Discussion - Pseudofolliculitis Barbae Under 38 C.F.R. § 4.118, the Veteran's skin disability (pseudofolliculitis barbae) is rated by analogy to dermatitis under DC 7806. The Board notes that there is no indication of disfigurement of the head, face, or neck due to the service-connected pseudofolliculitis barbae. Diagnostic Code 7806 provides that a noncompensable rating is warranted if less than five percent of the entire body or less than five percent of exposed areas are affected, and; no more than topical therapy was required during the past twelve-month period. A 10 percent rating is warranted if at least five percent, but less than 20 percent, of the entire body, or at least five percent, but less than 20 percent, of exposed areas are affected, or; if intermittent systemic therapy such as cortico-steroids or other immunosuppressive drugs were required for a total duration of less than six weeks during the past twelve-month period. A 30 percent rating is warranted if 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas are affected, or; if systemic therapy such as corticosteroids or other immune-suppressive drugs were required for a total duration of six weeks or more, but not constantly, during the past twelve-month period. A 60 percent rating is warranted if more than 40 percent of the entire body or more than 40 percent of exposed areas are affected, or; if constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs were required during the past twelve-month period. Importantly, in March 2016 the United States Court of Appeals for Veterans Claims (Court) issued a decision in Johnson v. McDonald, 27 Vet. App. 497 (2016), which addresses VA's interpretation of 38 C.F.R. § 4.118, Diagnostic Code 7806. The Court found that the language of Diagnostic Code 7806 provides for a 60 percent rating for constant or near constant use of corticosteroids, whether or not such steroids were applied topically or through an oral medication. The Court's determination in Johnson is under appeal and has not been finally adjudicated. A stay has been put in place pending final resolution of this matter; however, the stay does not extend to cases that have been advanced on the docket, as this one has. As such, the holding in Johnson applies, notwithstanding the pending appeal and stay. The Board observes that the Veteran has reported that he cannot shave his facial hair because it causes skin bumps, in-grown hairs with regrowth, skin irritation, and itching on his face and neck. See, e.g., January 2012 statement. He also reported using over-the-counter creams for years on his face and was presently using prescription creams including a 2.5 percent hydrocortisone cream. VA treatment notes reflect a prescription for cortisone and Eucerin cream in June and July 2009. Subsequent VA notes do not reflect use of over-the-counter or prescription hydrocortisone cream or any other cream specifically for his beard area. The evidence does show he was prescribed an anti-fungal cream for athlete's foot and was using a topical Capsaicin cream for pain. Records also show he was prescribed a steroid eye drop for his eye and urea cream for his feet. A February 2012 VA examination report reflects that there was no scarring or disfigurement of the head, face, or neck and that the Veteran had not used oral or topical medications for skin treatment in the previous 12 months. The examiner noted that the Veteran reported subjective symptoms of tenderness on his chin; a papule was noted on the chin and the examiner stated there was no problem with pseudofolliculitis barbae so long as the Veteran didn't shave. In the Veteran's July 2012 notice of disagreement (NOD), he stated that he was entitled to a compensable rating for his pseudofolliculitis barbae because he had been forced to wear a beard for over 40 years. The Board acknowledges the Veteran's contentions; however, having a beard is not a disability for VA purposes. A VA examination report dated September 2012 reflects that the Veteran reported treatment of occasional outbreaks related to shaving his face with topical hydrocortisone cream during the previous 12 months. The provider did not indicate the frequency or duration of the reported hydrocortisone treatment. The provider stated that the skin condition involved less than five percent of total body area and less than five percent of exposed area. The Veteran received a third VA skin examination in June 2014. The provider noted that the Veteran used hydrocortisone cream on the skin beneath his beard for skin irritation; this treatment included constant topical steroid cream use during the previous 12 months. The pseudofolliculitis impacted less than five percent of total body area and less than five percent of exposed body area. As each of the examiners found that the Veteran's pseudofolliculitis barbae covered less than five percent of his body; a compensable rating would not be warranted based on the presence of a sizeable and visible impairment of the skin. However, as noted above, the Veteran may be entitled to a compensable rating in the absence of a visible skin disability based on his frequent use of certain medications. In this regard, the Board notes that the Veteran reported constant use of topical steroid cream for the previous year in his June 2014 VA examination. Under Johnson, he is thus entitled to the maximum 60 percent rating for his pseudofolliculitis barbae. The remaining question is the effective date. The Veteran filed the pending claim seeking a higher evaluation for his pseudofolliculitis barbae in November 2011. His February 2012 VA examination reflects no use of hydrocortisone cream. Contemporaneous VA treatment notes support this conclusion. The September 2012 examination report does reflect use of hydrocortisone cream. Although the duration of treatment or frequency of treatment was not discussed in the examination report, the Board finds that, after affording the Veteran the benefit of the doubt, this is the earliest date that an increased rating based on use of topical corticosteroids can be granted. As such, a 60 percent rating for pseudofolliculitis barbae is warranted effective September 6, 2012. ORDER Entitlement to service connection for a right arm disability is denied. Subject to the law and regulations governing payment of monetary benefits, a rating of 60 percent for the Veteran's heart condition, but no greater, is granted for the period beginning with the date of claim until August 11, 2009. As of August 12, 2009, a rating in excess of 30 percent for cardiomegaly is denied. Subject to the law and regulations governing payment of monetary benefits, a 60 percent rating for pseudofolliculitis barbae, but no greater, is granted effective September 6, 2012. REMAND Manlincon/Issuance of SOC The issues of entitlement to an earlier effective date for the grant of service connection for cardiomegaly; entitlement to a rating in excess of 20 percent for a right shoulder disability; entitlement to service connection for a bilateral eye disability, to include cataracts; entitlement to service connection for a chronic headache disability; entitlement to service connection for a disability manifested by dizziness; entitlement to service connection for left ear hearing loss; and entitlement to service connection for a respiratory disability were denied by the RO. A May 2013 rating decision granted service connection for the right shoulder and denied service connection for dizziness, left ear haring loss, headaches, an eye disability, and a respiratory disability. An October 2014 rating decision granted service connection for cardiomegaly, assigning an effective date. The Veteran submitted timely notices of disagreement in May 2013 (right shoulder, left ear hearing loss, respiratory disorder, headaches, bilateral eyes), May 2014 (dizziness and others repeated), and November 2014 (earlier effective date for cardiomegaly) regarding each of these claims and these claims were not withdrawn. Hypertension VA regulations require that hypertension or isolated systolic hypertension be confirmed by readings taken two or more times on at least three different days. See 38 C.F.R. § 4.104, DC 7101. The evidence of record does not show a current diagnosis consistent with these regulatory guidelines. Post-service medical records reflect the Veteran established care at the VA in January 2009. VA treatment records from January through April 2009 reflect blood pressure readings of 125/90, 126/81, 127/72, 132/80, and 153/100; records reflect the Veteran was taking not blood pressure medication during this time period. In February 2009, the Veteran denied a history of hypertension in a pre-anesthetic evaluation note. However, in April 2009, he reported a history of hypertension to his VA internist. The internist placed him on blood pressure medication despite normal readings up until that point, including a reading of 115/71 on that date. The Veteran's file was sent for a hypertension opinion; the examination report dated May 2014 is inadequate. The Veteran has made several contentions regarding the etiology of his hypertension. He asserts: (1) that it must have preceded his cardiomegaly due to the May 2014 VA hypertension examiner's opinion; (2) he was exposed to salty foods and pork products on a regular basis through prepared foods while in service and ingestion of salt and pork leads to hypertension; (3) his in-service diagnosis of cardiomegaly increased his daily stress level, which causes hypertension. See June 2015 DRO hearing transcript; August 2010 statement in support of claim. On remand, the RO is directed to provide the Veteran a VA hypertension examination with a qualified professional to determine the nature and etiology of his claimed hypertension disability. The examiner must discuss the Veteran's contentions. Acquired Psychiatric Disorder The Veteran asserts that he has an acquired psychiatric disorder related to events of service. It does not appear the RO has ever afforded the Veteran a VA psychiatric evaluation in part because it determined that the claimed PTSD stressors could not be verified and in part because there was no diagnosis of PTSD. Under Clemons v. Shinseki, 23 Vet. App. 1, 4-5 (2009), the RO should have conducted all appropriate development to ascertain whether the Veteran had any acquired psychiatric disorder related to service. On remand, this development should be completed. TDIU and Combined Ratings The Veteran asserts that he is totally disabled and unable to obtain and sustain substantially gainful employment due to his numerous disabilities; it is unclear if his service-connected disabilities alone are severe enough to preclude substantially gainful employment. For instance, an August 2010 VA treatment note reflects the Veteran's non-service-connected low back disability was completely disabling. The provider's opinion was in support of the Veteran's claim for non-service-connected pension benefits through VA. A Social Security Administration (SSA) decision dated November 2010 reflects a finding that the Veteran was unable to obtain and maintain substantially gainful employment, including the minimal physical requirements of sedentary work, due to numerous disabilities, including: chronic neck, back, knee, and foot pain, decreased vision, and major depressive disorder and PTSD. At present, none of these disabilities are subject to service connection. A December 2010 VA treatment note contains a medical opinion that the Veteran was completely disabled due to hypertension, cardiomegaly, osteoarthritis, low vision, and major depressive disorder. This opinion was provided in support of the Veteran's claim for non-service-connected pension benefits through VA. The Veteran's currently-assigned disability ratings meet the criteria for consideration of TDIU on a schedular basis. On remand, the RO is directed to undertake appropriate development to ascertain the impact of his service-connected disabilities, alone, on his activities of daily living and occupational ability. In regard to the Veteran's claim seeking entitlement to higher combined evaluations, the matter must be remanded as inextricably intertwined with the issues being remanded for additional development. On remand, all missing VA treatment records should be obtained. Accordingly, the case is REMANDED for the following action: (This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. Obtain any missing VA treatment notes and associate them with the claims file. 2. After obtaining any outstanding records and conducting any appropriate development, issue an SOC regarding the Veteran's claims for entitlement to an earlier effective date for the grant of service connection for cardiomegaly; entitlement to a rating in excess of 20 percent for a right shoulder disability; entitlement to service connection for a bilateral eye disability, to include cataracts; entitlement to service connection for a chronic headache disability; entitlement to service connection for a disability manifested by dizziness; entitlement to service connection for left ear hearing loss; and entitlement to service connection for a respiratory disability. 3. After updated records have been obtained, schedule the Veteran for a VA psychiatric examination with an appropriate professional to determine the nature and etiology of his claimed psychiatric disability. All psychiatric disabilities found to be present should be noted. A full medical history should be recorded and a standard medial nexus opinion should be included in the examination report. In addition, the examiner should state whether it is at least as likely as not Veteran has a current psychiatric disability was caused or aggravated by the Veteran's service-connected disabilities. The entire claims file and a copy of this REMAND must be made available to and reviewed by the examiner. Full rationale must be provided for the opinions expressed. Citation to pertinent medical treatise literature is encouraged but not required. If an opinion cannot be expressed without resort to speculation, the provider must state the reasons why resort to speculation would be necessary. 4. After updated records have been obtained, request an addendum medical opinion regarding the nature and etiology of the Veteran's claimed hypertension. An in-person examination is not warranted unless the provider deems one necessary. The entire claims file and a copy of this REMAND must be made available to and reviewed by the examiner. The examiner must discuss the Veteran's numerous lay statements and theories of entitlement to service connection for hypertension. The examiner is asked to respond to the following inquires: a. Is it at least as likely as not the Veteran's hypertension had onset during service? b. Is it at least as likely as not the Veteran's hypertension was caused by any event of service, to include ingestion of processed foods containing salt and/or pork products or related to increased stress due to his cardiomegaly diagnosis? c. Is it at least as likely as not the Veteran's service-connected cardiomegaly caused his hypertension? d. Is it at least as likely as not the Veteran's service-connected cardiomegaly aggravated his hypertension? Full rationale must be provided for the opinions expressed. Citation to pertinent medical treatise literature is encouraged but not required. If an opinion cannot be expressed without resort to speculation, the provider must state the reasons why resort to speculation would be necessary. 5. After the above development has been completed, adjudicate the issues of entitlement to a TDIU and entitlement to a combined evaluation greater than 30 percent effective April 16, 2009, and greater than 40 percent effective May 19, 2010 in light of the pertinent evidence of record. If the benefits requested on appeal are not granted, the Veteran should be furnished a Supplemental Statement of the Case (SSOC), which addresses all of the pertinent evidence, and provides an opportunity to respond. The case should then be returned to the Board for further appellate consideration, if in order. By this remand, the Board intimates no opinion as to any final outcome warranted. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ STEVEN D. REISS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs