Citation Nr: 1804027 Decision Date: 01/23/18 Archive Date: 01/31/18 DOCKET NO. 14-32 357 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Huntington, West Virginia THE ISSUES 1. Entitlement to service connection for chronic fatigue syndrome. 2. Entitlement to service connection for a gastroesophageal disability, to include gastroesophageal reflux disease (GERD). 3. Entitlement to service connection for a joint pain disability, to include fibromyalgia. 4. Entitlement to an increased rating in excess of 50 percent for posttraumatic stress disorder (PTSD). 5. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Veteran represented by: Jan Dils, Attorney WITNESSES AT HEARING ON APPEAL Veteran and his spouse ATTORNEY FOR THE BOARD K. Thompson, Associate Counsel INTRODUCTION The Veteran served on active duty in the United States Army from January 1987 to May 1991. This matter comes before the Board of Veterans' Appeals (Board) on appeal from March 2012 and December 2013 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Huntington, West Virginia. In October 2017, a Board videoconference hearing was held before the undersigned; a transcript of the hearing is associated with the record. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C. § 7107(a)(2) (2012). The issue(s) of entitlement to service connection for GERD is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. In October 2017, the Veteran submitted testimony on the record at the Board hearing that he wanted to withdraw his appeal with respect to his service connection claim for chronic fatigue syndrome. 2. The Veteran served in the Southwest Asia Theater of operations. 3. The Veteran has a current diagnosis of fibromyalgia. 4. The Veteran's PTSD has resulted in occupational and social impairment, with deficiencies in most areas, such as work, family relations, judgment, thinking, and mood. 5. The Veteran meets the schedular criteria for TDIU consideration and the competent evidence of record indicates that the Veteran is unable to maintain substantially gainful employment due to his service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for withdrawal of a substantive appeal by the Veteran on the issue of entitlement to service connection for chronic fatigue syndrome have been met. 38 U.S.C. §§ 7105(b)(2), (d)(5) (2012); 38 C.F.R. § 20.204 (2017). 2. The criteria for service connection for fibromyalgia have been met. 38 U.S.C. §§ 1110, 1117, 1154(a), 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.317. 3. The criteria for an evaluation of 70 percent, and no higher, for PTSD, have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 4.7, 4.124(a), 4.130, Diagnostic Code 9411. 4. The criteria for an award of TDIU have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist Under the Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations, VA has a duty to notify and assist the claimant in substantiating a claim for VA benefits. See 38 U.S.C. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). In this decision, the Board grants service connection as well as a 70 percent rating for TDIU and PTSD. Considering the discussion at the time of the Board hearing, this constitutes a full grant of the benefits sought as to the benefits considered on the merits in this decision. See Board transcript, page 19. II. Withdrawn Issue Under 38 U.S.C. § 7105, the Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. An appeal may be withdrawn in writing or in testimony at a hearing. 38 C.F.R. § 20.204. In this case, the Veteran withdrew the issue of entitlement to service connection for chronic fatigue syndrome at the October 2017 Board hearing; hence, there remain no allegations of errors of fact or law for appellate consideration as it relates to this issue. Accordingly, the Board does not have jurisdiction to review the appeal as to this issue, and it is dismissed without prejudice. III. Service Connection Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Service connection means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service, or if preexisting service, was aggravated therein. 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). To establish entitlement to service connection, there must be: (1) competent and credible evidence confirming the Veteran has the claimed disability or at least has since filing the claim; (2) competent and credible evidence of in-service incurrence or aggravation of a relevant disease or injury; and (3) competent and credible evidence of a nexus or link between the in-service injury or disease and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may be established on a presumptive basis for a Persian Gulf veteran who exhibits objective indications of chronic disability resulting from undiagnosed illness that became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2016, and which by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C. § 1117; 38 C.F.R. § 3.317(a)(1) (VA has adopted an interim final rule extending this date to December 31, 2021). In claims based on undiagnosed illness, unlike those for direct service connection, there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Gutierrez v. Principi, 19 Vet. App. 1, 8-9 (2004). Notably, laypersons are competent to report objective signs of illness. Id. A "qualifying chronic disability" for purposes of 38 U.S.C. § 1117 is a chronic disability resulting from (A) an undiagnosed illness, (B) a medically unexplained chronic multisymptom illness (such as chronic fatigue syndrome (CFS), fibromyalgia, or irritable bowel syndrome) that is defined by a cluster of signs or symptoms, or (C), any diagnosed illness that the Secretary determines in regulation prescribed under 38 U.S.C. § 1117(d) warrants a presumption of service connection. 38 U.S.C. § 1117(a)(2); 38 C.F.R. § 3.317(a)(2)(i)(B). "Objective indications of chronic disability" include both "signs," in the medical sense of objective evidence perceptible to a physician, and other, non-medical indicators that are capable of independent verification. To fulfill the requirement of chronicity, the illness must have persisted for a period of six months. 38 C.F.R. § 3.317(a)(2), (3). Signs or symptoms that may be manifestations of undiagnosed illness include, but are not limited to, the following: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurologic signs or symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the respiratory system (upper or lower); (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; (12) abnormal weight loss; and (13) menstrual disorders. 38 C.F.R. § 3.317(b). The Board notes that, effective July 13, 2010, VA has amended its adjudication regulations governing presumptions for certain Persian Gulf War Veterans. Such revisions amend § 3.317(a)(2)(i)(B) to clarify that chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome are examples of medically unexplained chronic multisymptom illnesses and are not an exclusive list of such illnesses. Additionally, the amendment removes § 3.317(a)(2)(i)(B)(4) which reserves to the Secretary the authority to determine whether additional illnesses are "medically unexplained chronic multisymptom illnesses" as defined in paragraph (a)(2)(ii) so that VA adjudicators will have the authority to determine on a case-by-case basis whether additional diseases meet the criteria of paragraph (a)(2)(ii). These amendments are applicable to claims pending before VA on October 7, 2010, as well as claims filed with or remanded to VA after that date. See 75 Fed. Reg. 61,997 (Oct. 7, 2010). Compensation under 38 U.S.C. § 1117 shall not be paid if: (1) there is affirmative evidence that an undiagnosed illness was not incurred during active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War; (2) if there is affirmative evidence that an undiagnosed illness was caused by a supervening condition or event that occurred between the veteran's most recent departure from active duty in the Southwest Asia theater of operations during the Persian Gulf War and the onset of the illness; or (3) if there is affirmative evidence that the illness is the result of the veteran's own willful misconduct or the abuse of alcohol or drugs. 38 C.F.R. § 3.317(c). The term "Persian Gulf Veteran" means a veteran who served on active military, naval, or air service in the Southwest Asia Theater of operations during the Persian Gulf War. 38 C.F.R. § 3.317(d)(1). The Southwest Asia Theater of operations includes Iraq, Kuwait, Saudi Arabia, the neutral zone between Iraq and Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, the Gulf of Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea, the Red Sea, and the airspace above these locations. See 38 U.S.C. § 1117; 38 C.F.R. § 3.317(d)(2). The Persian Gulf War period runs from August 2, 1990 to December 31, 2016. 38 U.S.C. § 101(33); 38 C.F.R. § 3.317(a)(1)(i). The Veteran seeks service connection for joint pain, including fibromyalgia, to include as due to chronic undiagnosed illness. At the outset, the Board notes that the Veteran served in the Southwest Asia Theater of operations from October 1990 to April 1991. VA medical records show a November 2013 diagnosis of fibromyalgia. At that time, the Veteran complained of neck and back pain, and pain and numbness in the right upper extremity. Upon physical examination, the physician noted tenderness over the upper trapezius, over the shoulder joint, over the parathoracic muscles. The physician specifically noted tenderness over the knees, at the elbow and the hips as a sign for fibromyalgia. The physician also noted the Veteran's poor sleep as a sign for fibromyalgia. At the October 2017 Board hearing, the Veteran testified that he began taking gabapentin after he was diagnosed with fibromyalgia in November 2013 and that he is still currently taking it. He stated that he continues to have issues with pain in different areas of his body and mental "fogginess" as a result of the fibromyalgia and the medication. Under diagnostic code 5025, 38 C.F.R. § 4.71(a), the criteria for a 10 percent disability rating for fibromyalgia consists of widespread musculoskeletal pain and tender points, with or without associated fatigue, sleep disturbance, stiffness, paresthesias, headache, irritable bowel symptoms, depression, anxiety, or Raynaud's-like symptoms that require continuous medication for control. Both the Veteran's statements reporting his symptoms and the symptoms listed within the VA medical records show that the Veteran's fibromyalgia fits within these diagnostic criteria by manifesting most of these symptoms. With the Veteran's service in Southwest Asia and his fibromyalgia disability manifesting to a 10 percent or more disabling, he has met the criteria necessary to establish presumptive service connection. See 38 C.F.R. §§ 3.317, 4.71(a). In light of the foregoing, and resolving all reasonable doubt in the Veteran's favor, the Board finds that service connection is warranted. The evidence shows that the Veteran currently experiences from fibromyalgia, which has been manifest to a degree of at least 10 percent under the pertinent rating criteria. For these reasons, the Board finds that service connection for fibromyalgia is warranted. 38 C.F.R. § 3.317. III. Increased Rating Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity resulting from disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that rating. 38 C.F.R. § 4.7. Otherwise, the lower rating will be assigned. Id. The Court has held that in determining the present level of a disability for any increased evaluation claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. The Veteran bears the burden of presenting and supporting his claim for benefits. 38 U.S.C. § 5107(a). In its evaluation, the Board considers all information and lay and medical evidence of record. 38 U.S.C. § 5107(b). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Board gives the benefit of the doubt to the claimant. Id. The RO has rated the Veteran's PTSD under the General Rating Formula for Mental Disorders, which assigns ratings based on particular symptoms and the resulting functional impairment(s). See 38 C.F.R § 4.130, Diagnostic Code 9411 (PTSD). The General Rating Formula is as follows: A 50 percent rating is warranted where there is 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. Id. A 70 percent rating is warranted where there is 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. A 100 percent rating is warranted for 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. The psychiatric symptoms listed in the above rating criteria are not exclusive, but are examples of typical symptoms for the listed percentage ratings. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Although the Veteran's symptomatology is the primary consideration, the Veteran's level of impairment must be in "most areas" applicable to the relevant percentage rating criteria. Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). According to the applicable rating criteria, when evaluating a mental disorder, the frequency, severity, duration of psychiatric symptoms, length of remissions, and the veteran's capacity for adjustment during periods of remission must be considered. See 38 C.F.R. § 4.126(a). In addition, the evaluation must be based on all the evidence of record that bears on occupational and social impairment, rather than solely on the examiner's assessment of the level of disability at the moment of the examination. Id. Further, when evaluating the level of disability from a mental disorder, the extent of social impairment is considered, but the rating cannot be assigned solely on the basis of social impairment. See 38 C.F.R. § 4.126(b). The Global Assessment of Functioning (GAF) scale reflects the psychological, social and occupational functioning under a hypothetical continuum of mental illness. See American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV). See also Carpenter v. Brown, 8 Vet. App. 240, 243 (1995); 38 C.F.R. § 4.130. According to the DSM-IV, a GAF score of 61-70 denotes some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. A GAF score of 51-60 indicates moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). A GAF score of 41-50 indicates serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). An examiner's classification of the level of psychiatric impairment, by words or a GAF score is a factor for consideration and not determinative of the percentage VA disability rating to be assigned. See also 38 C.F.R. § 4.126(a). Service connection for PTSD was granted in a March 2012 rating decision. The Veteran filed a claim for an increased evaluation for PTSD in June 2013. The Veteran was afforded a VA examination in connection with his claim for an increased rating in December 2013. The examiner described the Veteran's level of occupational and social impairment as occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. The Veteran reported ongoing symptoms of PTSD. He described familial problems, and a lack of social contacts outside of his immediate family. He also described a lack of interest in certain hobbies such as fishing, but stated that he coached little league football. Upon mental status examination, the Veteran was oriented to person, place, and time, his affect was appropriate, speech was clear and coherent, hygiene was normal, and thought process and content was unremarkable. The Veteran reported sleep disturbances with difficulty initiating and maintaining sleep. Occupationally, the Veteran reported that he last worked in May 2013, when he was laid off. He reported difficulty getting along with his co-workers and frequent tardiness due to his inability to get out of bed. He denied ever being written up for inappropriate behavior while employed. The examiner found that the Veteran would experience mild occupational impairment upon attempts to maintain gainful employment. The Veteran submitted a private examination report from a private physician, Dr. J.A., in June 2016. On mental status examination, Dr. J.A. found that the Veteran's self-presentation was "reticent, vague, irritable, and guarded." His concentration was fair, his affect was flat and diminished, his speech was coherent but sparse and hesitant, and his ability to abstract was "marked by fluctuation between abstract and concrete levels." The Veteran was partially oriented as to time, and did not know the date but knew the month and year. His memory was intact. The Veteran reported low-level depression twice a month, and reported felling agitated and pressured "a lot lately." He reported a fair energy level and chronic fatigue. His sleep patterns were disturbed. The Veteran stated that he began to lost interest in social hobbies and that he would not enjoy any of those activities. He described feelings of agitation or alienation from other people and that he did not feel comfortable talking with anyone about personal things. He also related feeling that his family would be better off without him and that he had few or no interpersonal affiliations. Dr. J.A. noted that the Veteran's impairment in social functioning was rated as moderate, definite impairment, but some aspects of social functioning remaining. PTSD symptoms severely affected the Veteran's interpersonal and familial relationships. Occupationally, Dr. J.A. noted that the Veteran was not working at that time, but that his PTSD moderately impaired his abilities to work but that some aspects of occupational functioning remained intact. Ultimately, Dr. J.A. found that the Veteran's current level of impairment more closely approximated a 70 percent rating than a 50 percent rating, stating that the Veteran had deficiencies in work, family relationships, mood, and including irritability, disturbances in motivation and mood, and inability to establish and maintain effective relationship. . At the October 2017 Board hearing, the Veteran testified that he has had panic attacks as many as four or five times a day. He also testified that he has no control over his emotions, particularly his anxiety and anger, and that he fears the lack of control over his anger. He stated that he once "flew off the handle" in a conversation and punched walls in his house. When asked about his statement in the June 2016 private examination that his family would be "better off without him," the Veteran stated that he struggles with suicidal ideations and that he has thought about it more often than he would like. He also testified that his PTSD affected his work in that he could not concentrate on tasks and would get overwhelmed. He stated that things have to be done in a certain way and that he can't deal with changes in routines or plans. On review of the record, the Board finds that the disability picture presented by the Veteran's PTSD warrants an evaluation of 70 percent, and no higher. The Board notes that the evidence indicates the Veteran's service-connected PTSD is manifested by occupational and social impairment, with deficiencies in most areas. The Board notes that the VA treatment records indicated the Veteran had problems with work, family relations, judgment, and mood. He also testified to periods of unprovoked violence and admitted that he could not adapt to changing or stressful situations. The Veteran has also endorsed suicidal ideations, which is supportive of a higher rating. The Board notes that suicidal ideation alone may cause occupational and social impairment with deficiencies in most areas. See Bankhead v. Shulkin, 2017 U.S. App. Vet. Claims LEXIS 722 (May 19, 2017) (the language of the regulation indicates that the presence of suicidal ideation alone, that is, a veteran's thoughts of his or her own death or thoughts of engaging in suicide-related behavior, may cause occupational and social impairment with deficiencies in most areas). As such, affording the Veteran the benefit of the doubt, the Veteran's PTSD manifests symptoms more nearly approximating an evaluation of 70 percent disabling. Therefore, an evaluation of 70 percent disabling is granted. The symptoms and overall impairment did not, however, more nearly approximate the total occupational and social impairment required for a 100 percent rating. Although the Veteran has admitted to suicidal ideations, there is no evidence that the Veteran has been in persistent danger of hurting himself or others. Furthermore, there is no evidence of total social impairment warranting a total disability rating. While the Veteran is socially isolated, there is no indication of gross impairment of thought processes or communication. Thus, neither the symptoms nor overall impairment caused by the Veteran's service-connected PTSD more nearly approximated total occupational and social impairment. Further, as noted above, the Veteran's representative indicated that a 70 percent rating would satisfy the appeal as to this claim. IV. TDIU Total disability ratings for compensation based on individual unemployability may be assigned where the schedular rating is less than total if it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of (1) a single service-connected disability ratable at 60 percent or more, or (2) as a result of two or more disabilities, provided 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. See 38 C.F.R. §§ 3.340, 3.341, 4.16(a). Entitlement to a TDIU requires the presence of impairment so severe that it is impossible for the average person to secure and follow a substantially gainful occupation. See 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. In reaching such a determination, the central inquiry is "whether the veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Consideration may be given to the Veteran's level of education, special training, and previous work experience in arriving at a conclusion, but not to his age or the impairment caused by non-service- connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19. Here, the service-connected disabilities meet the schedular criteria. At the time the Veteran filed his application for TDIU, he was service-connected for PTSD, evaluated as 50 percent disabling; left knee degenerative joint disease with chondromalacia, evaluated as 10 percent disabling; right knee degenerative joint disease with chondromalacia, evaluated as 10 percent disabling; and tinnitus, evaluated as 10 percent disabling. The Veteran's combined disability rating for his service-connected disabilities is 70 percent. Thus, he meets the schedular criteria for a TDIU under 38 C.F.R. § 4.16(a). A vocational rehabilitation initial evaluation report from July 2009 found that the Veteran "has skills and experiences that he could build on to get a job but without further education, he is very limited in what he can do with his disability." There is evidence in his vocational rehabilitation records that the Veteran took some post-secondary courses, but the evidence does not show that the Veteran received a degree. The Veteran confirmed at the October 2017 hearing that he had three years of college and didn't study anything other than general courses. As stated above, the Veteran testified at the Board hearing in October 2017 that his PTSD was a factor in his employment in that he could not concentrate on his work, would get overwhelmed or mad and "walk away." He also stated that he was not above to perform his duties at work due to his physical and psychiatric disabilities. Physically, his service-connected knee disabilities prevented him from standing and kneeling to work on the mining equipment. His service-connected shoulder disability also impacted his ability to reach and manipulate. Psychiatrically, the Veteran testified that he also had difficulty getting along with others and would isolate himself. He stated that if he couldn't isolate himself, he would get agitated and lose his temper. A December 2017 VA knee examination stated that the functional impact of the Veteran's service-connected knee disabilities was that the Veteran would have "difficulty doing physical labor that required climbing, prolonged walking or standing." A December 2017 VA shoulder examination found that the functional impact of the Veteran's service-connected shoulder disability was that the Veteran would have difficulty doing physical labor that required lifting, pushing, pulling, or overhead work. The examiners noted that the respective knee or shoulder disabilities did not prevent the Veteran from doing sedentary work. The private examination from Dr. J.A. found that PTSD impaired the Veteran's employment. The evidence supports a finding that the Veteran's PTSD, right shoulder, bilateral knee, bilateral hearing loss, and tinnitus cause the Veteran's unemployability. In this case, considering the Veteran's previous employment, education level and training, in light of the severity of his PTSD, the evidence does not show that the Veteran is able to obtain and maintain employment consistent with his employment and educational background. Therefore, the Board concludes that the award of a TDIU is warranted. Accordingly, in considering the severity of the Veteran's service-connected disabilities, the medical evidence of record, as well as his employment and education history, and in affording him the benefit-of-the-doubt, the Board finds that the Veteran's service-connected disabilities render him unemployable. The benefit sought on appeal is therefore granted. ORDER The appeal for the issue of entitlement to service connection for chronic fatigue syndrome is dismissed. Entitlement to service connection for a joint pain disability, including fibromyalgia, is granted. Entitlement to a disability rating of 70 percent disabling for posttraumatic stress disorder (PTSD) is granted throughout the appeal period, subject to the law and regulations governing the payment of monetary benefits. Entitlement to a TDIU is granted, subject to the law and regulations governing the payment of monetary benefits. REMAND The Board regrets further delay, but additional development is necessary to adjudicate the remaining claims. Regarding a disability manifesting with gastroesophageal symptoms, another examination must be conducted. The Veteran was diagnosed with GERD in the January 2012 VA examination, and his VA treatment records reflect ongoing treatment for GERD. The Veteran indicated at the October 2017 Board hearing that his symptoms were perhaps more indicative of irritable bowel syndrome than GERD. The Veteran testified that his symptoms began in-service and continued until the present. Medical records from March 2015 note a diagnosis of postprandial diarrhea, which the physician deemed a suspect component of IBS. Additionally, the Veteran's service treatment records contain treatment for stomach cramps, diarrhea, and constipation. On remand, a comprehensive examination that addresses all his symptoms as they may relate to a gastroesophageal disability must be completed. Accordingly, the case is REMANDED for the following action: (Please note, 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 relevant and outstanding VA treatment records and associate them with the electronic claims file. 2. Thereafter, the Veteran should also be scheduled for a VA examination before an appropriate physician to determine the etiology of any gastroesophageal disorder to include gastroesophageal reflux disease (GERD). The Veteran's claims file and a copy of this remand should be provided to the examiner and the examination report should reflect that these items were reviewed. The examiner is asked to perform all indicated tests and studies and provide an opinion as to the following: (a) Identify all current gastroesophageal disorders associated with the Veteran. (b) Is it at least as likely as not that any identified gastroesophageal disorder manifested during, or as a result of, active military service? (c) The examiner should also identify whether the Veteran experiences from any symptoms associated with an undiagnosed illness or a functional gastrointestinal disorder. His service in the Gulf War is not disputed. A full rationale must be provided for any opinion offered. If an opinion cannot be offered without resort to mere speculation, the examiner must indicate why this is the case and indicate what additional evidence, if any, would allow for a more definitive opinion. 3. After completing all actions set forth above and any further action needed as a consequence of the above development, readjudicate the claims on appeal, to include reviewing the issue of service connection for a gastroesophageal disability based on all evidence of record to include the recent VA examination. If the benefit on appeal remains denied, the RO should furnish to the Veteran and his representative an appropriate Supplemental Statement of the Case and allow the appropriate time for response. Then return the case to the Board for further appellate review. The Veteran has the right to submit additional evidence and argument on the matter or 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. §§ 5109B, 7112 (2012). ______________________________________________ Nathaniel J. Doan Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs