Citation Nr: 18140914 Decision Date: 10/09/18 Archive Date: 10/09/18 DOCKET NO. 13-31 189 DATE: ORDER Entitlement to service connection for migraines is granted. Entitlement to an initial rating of 70 percent, and no higher, for service-connected posttraumatic stress disorder (PTSD) from August 12, 2010, is granted. REMANDED Entitlement to service connection for sleep apnea is remanded. Entitlement to service connection for chest pain is remanded. Entitlement to service connection for back disability is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. Resolving reasonable doubt in the Veteran’s favor, his migraines are due at least in part to his service-connected PTSD and traumatic brain injury (TBI). 2. Since the effective date of service connection, the Veteran’s PTSD has been manifested by occupational and social impairment with deficiencies in most of the areas, of work, school, family relations, judgment, thinking, and mood. CONCLUSIONS OF LAW 1. The criteria for secondary service connection for migraines are met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.310(a). 2. The criteria for an initial rating of 70 percent, and no higher, for PTSD are met from August 12, 2010. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.7, 4.125, 4.130, Diagnostic Code 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 2002 to August 2006, with additional service in the Air Force National Guard and Air Force Reserve. Although the claim for service connection for migraine headaches was previously denied in a January 2009 rating decision, relevant official service department records that existed at the time of the January 2009 decision and had not been associated with the claims file at that time have now been associated with the claims file. Accordingly, the claim will be reconsidered on the merits, without addressing any threshold issue of whether new and material evidence has been received to reopen the claim. 38 C.F.R. § 3.156(c). The issue of entitlement to a TDIU has been raised by the record, including the Veteran’s reports that he lost jobs due to the effects of PTSD, including problems interacting with his co-workers, and has been added to the appeal as part and parcel to the Veteran’s claim for a higher initial rating for his PTSD disability. See Rice v. Shinseki, 22 Vet. App. 447 (2009) (holding that a request for a TDIU, whether expressly raised by a veteran or reasonably raised by the record, is not a separate “claim” for benefits, but rather, can be part of a claim for increased compensation). 1. Entitlement to service connection for migraines is granted. A July 2018 letter from the Veteran’s treating private physician shows the Veteran has a current diagnosis of migraines, and the private physician opined that the Veteran’s service-connected PTSD and TBI have contributed to his migraines. The February 2017 VA examiner, while not confirming a migraine diagnosis, also attributed the Veteran’s headache symptoms to medical and mental health conditions. These opinions are in accord with the evidence in the Veteran’s claims file. The Veteran submitted an article showing a higher incidence of migraines in those veterans returning from deployment with traumatic brain injuries and an article suggesting that the presence of PTSD may be associated with an increased predisposition to the development of migraines. See July 2018 Submission. In addition, the Veteran reported that he has consistently experienced headaches following explosions during his deployment in the Persian Gulf War. See September 2017 Veteran’s Statement; see also June 2014 VA Treatment Record (noting Veteran’s report of experiencing headaches for the last 8-9 years). Accordingly, viewing the evidence as a whole and in the light most favorable to the Veteran, service connection for migraines is warranted as secondary to the Veteran’s service-connected PTSD and TBI. 2. Entitlement to an initial rating of 70 percent, and no higher, for PTSD from August 12, 2010, is granted. Disability ratings are determined by the application of the facts presented to VA’s Schedule for Rating Disabilities (Rating Schedule) at 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 the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. 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. All benefit of the doubt will be resolved in the Veteran’s favor. 38 C.F.R. § 4.3. In the case of an initial rating, the period for consideration is that beginning with the effective date of service connection. See Fenderson v. West, 12 Vet. App. 119 (1999). The Veteran’s PTSD is evaluated under 38 C.F.R. § 4.130, Diagnostic Code 9411. Under the General Rating Formula for Mental Disorders, to include PTSD, a 30 percent rating is assigned for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactory, 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; or mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is assigned for 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; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent evaluation 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; intermittently illogical, obscure, or irrelevant speech; 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); and inability to establish and maintain effective relationships. A 100 percent evaluation is assignable where there is 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); and disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. This matter was certified to the Board after the August 4, 2014 implementation of the DSM-5, and therefore the DSM-5 applies to the claim. The Board notes that the DSM-5 eliminated the use of Global Assessment of Functioning scores. Evaluation under 38 C.F.R. § 4.130 is “symptom-driven,” meaning that “symptomatology should be the fact-finder’s primary focus when deciding entitlement to a given disability rating” under that regulation. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed.Cir.2013). The symptoms listed are not exhaustive, but rather “serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating.” Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In the context of determining whether a higher disability rating is warranted, the analysis requires considering “not only the presence of certain symptoms[,] but also that those symptoms have caused occupational and social impairment in most of the referenced areas” - i.e., “the regulation... requires an ultimate factual conclusion as to the Veteran’s level of impairment in ‘most areas.’” Vazquez-Claudio, 713 F.3d at 117-18; 38 C.F.R. § 4.130. Additionally, consideration is given to the frequency, severity, and duration of psychiatric symptoms, the length of remission, and the Veteran’s capacity for adjustment during periods of remission. The rating agency shall assign an evaluation 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. See 38 C.F.R. § 4.126(a). When evaluating the level of disability arising from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126 (b). In evaluating the level of disability, it is also necessary to evaluate such from the point of view of the Veteran working or seeking work. 38 C.F.R. § 4.2. Here, the Veteran’s PTSD has been rated 30 percent disabling from August 12, 2010, and 70 percent disabling from February 17, 2018. The evidence is at the very least in equipoise as to whether the level of impairment shown from the beginning of the appeal period is commensurate with occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, warranting a 70 percent rating. The primary consideration is the overall level of impairment, as due to any symptoms. In Vazquez-Claudio, the Federal Circuit held that the deficiencies that would warrant a 70 percent rating must be due to symptoms that are the equivalent in severity to those listed as examples in the 70 percent criteria. Such symptoms or their equivalent have been demonstrated in this case. Indeed, the record shows that, during the appeal period, the Veteran experienced severe anxiety, depressed mood, irritability and angry outbursts, suspiciousness, suicidal ideation, and inability to establish and maintain effective relationships. During the January 2011 VA contract examination, the Veteran reported insomnia, nightmares, anxiety, anger, depression, and isolation. The Veteran reported a good relationship with his mother and his child, and a somewhat distant relationship with his siblings because the Veteran isolated himself. The VA contract examiner noted the Veteran’s appearance and hygiene were appropriate. The VA contract examiner noted the Veteran’s restricted range of affect continues to persist. The Veteran’s mood was depressed. The Veteran’s speech was occasionally abnormally slow, but he showed otherwise normal communication, and normal thinking and judgment. The Veteran exhibited suspiciousness and does not trust people. The VA contract examiner noted a delusional history, including the Veteran believing that someone is out to get him but he does not know who it is, and noted that no delusion was observed at the time of examination. The Veteran reported no history of hallucinations and no suicidal or homicidal ideation. The VA contract examiner noted mild memory impairment. The VA contract examiner noted a decline in social and interpersonal relationships. The VA contract examiner opined that the Veteran’s psychiatric symptoms were mild or transient and cause occupational and social impairment with decrease in work efficiency and occupational tasks only during periods of significant stress. During the June 2014 VA examination, the Veteran reported symptoms of re-experiencing, avoidant behavior, negative alterations, and hyperarousal. The VA examiner noted symptoms of depressed mood, anxiety, and chronic sleep impairment. The Veteran was appropriately dressed with adequate hygiene, and his speech, thought process, insight, judgment, and cognitive functions were normal. No hallucinations or delusions were present, and no obsessions, compulsions or phobias were detected. The Veteran’s mood was mildly dysphoric and his affect was congruent with his mood. The Veteran’s thought content did not show suicidal or homicidal ideations, intentions, or plans. The VA examiner opined that the Veteran’s psychiatric disability resulted in 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 VA examiner noted the Veteran’s symptoms were the same as those shown in his 2011 examination. During the February 2018 VA contract examination, the Veteran reported suicidal ideation with no imminent plan and reported that suicide was not an option because of his son and his mother. The Veteran reported severe symptoms and exhibited severe clinical anxiety and severe mood dysregulation. The Veteran reported that he was fatigued, with apathy, low mood, a few panic attacks in the last few months, significant startle response, and that he was always wound up. The Veteran reported that he feels better off alone, experiences irritability and agitation, experiences poor attention and concentration, does not trust others, and that sometimes his anxiety causes him to leave his job. The VA contract examiner noted the Veteran was neatly dressed and oriented to date, time, and place. The VA contract examiner noted symptoms of depressed mood, anxiety, suspiciousness, panic attacks that occur weekly or less often, chronic sleep impairment, flattened affect, disturbances of motivation and mood, inability to establish and maintain effective relationships, and suicidal ideation. The VA contract examiner opined that the Veteran’s psychiatric disability resulted in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. The Veteran’s VA treatment records throughout the appeal period show the Veteran consistently experienced depressed mood, anxiety, anger, poor concentration and attention, poor motivation, low energy, problems with long-term and short-term memory, excessive guilt, flat or restricted or constricted or anxious or depressed or fatigued affect, avoidance, nightmares, flashbacks, diminished interest in pleasurable activities, anhedonia, feelings of detachment and estrangement from others, sleep impairment, hypervigilance, exaggerated startle response, panic attacks, distrust, social isolation, irritability, and outbursts (also described as emotional explosiveness or verbal aggression), and that he is quick to snap. In November 2013 treatment, the Veteran reported that he had lost jobs due to problems interacting with his co-workers, and that he avoids situations that evoke anger out of fear he would respond in an “out of control” way. Although the treatment records generally note that the Veteran denied suicidal ideation, he reported transient suicidal ideation over the last few years in January 2014 VA treatment. At that time, he explained that thoughts of his mother and his son prevented him from further engaging in such thoughts. The VA treatment records occasionally noted auditory hallucinations and the Veteran’s report of feeling paranoid. The VA treatment records occasionally noted slow or low volume speech, but generally noted normal speech, thoughts, insight, and judgment. The Veteran’s anxiety was noted to be severely disruptive and he was noted at times to be severely depressed. In a November 2010 questionnaire, the Veteran reported feeling anxious, depressed, and easily irritable, with problems with concentration and sleep. In an October 2013 statement, the Veteran reported that his work life, home life, and other activities are affected by his PTSD. He reported that he had lost jobs due to the effects of PTSD, that he has to stay away from people so that he does not blow up, that he does not engage with people, that he has not been able to maintain romantic relationships, that he snaps at people, and that he experiences depressed mood, panics, nightmares, and sleeping problems. Statements from others note that the Veteran has mood problems and spends a lot of time secluded. See September 2017 Veteran’s Friend’s Statement; November 2013 Veteran’s Mother’s Statement. The medical and lay evidence of record shows that the Veteran experienced anxiety, depression, angry outbursts, suspiciousness, suicidal ideation, and inability to establish and maintain effective relationships. The Veteran’s VA treatment records show the Veteran’s symptoms were fairly consistent in type and severity throughout the appeal period. The Veteran’s psychiatric disability resulted in occupational impairments, as he experienced trouble with concentration and anxiety and interacting with co-workers. He reported that he lost jobs due to problems interacting with co-workers. The Veteran also reported having no real friends anymore due to problems with trust, reported that he cannot maintain a romantic relationship, and reported that his relationships with his siblings have grown distant. Based on review of the VA and VA contract examinations, VA treatment records, and statements from the Veteran, his mother, and his friend, the Board finds the Veteran’s service-connected PTSD has caused occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and mood, for the entire appeal period. Therefore, from the effective date of service connection, the Veteran’s level of impairment more nearly approximates the 70 percent rating criteria. The Veteran does not meet the requirements for a rating in excess of 70 percent for his psychiatric disability. A rating higher than 70 percent requires total social and occupational impairment. The Veteran’s symptomatology does not result in total occupational and social impairment. The Veteran has maintained a good relationship with his mother, and with his child. VA treatment records noted that the Veteran’s appearance and hygiene were appropriate and he was fully oriented throughout the appeal period. Although occasional slow or quiet speech was noted, the Veteran generally presented with normal speech, thoughts, insight, and judgment. The record does not show persistent delusions or hallucinations. Although there are a few notations of potentially delusional paranoia or auditory hallucinations, the Veteran generally denied hallucinations and delusions. The record also does not show persistent danger of the Veteran hurting himself or others. The VA treatment records generally note that the Veteran denied suicidal and homicidal ideation. The Veteran reported transient suicidal ideation during the appeal period but explained that thoughts of his mother and his son prevented him from further engaging in such thoughts and that he had no imminent plan. His reports of outbursts were described as verbal aggression, and the Veteran reported that he avoids people and situations that will trigger outbursts. While some issues with memory and concentration are noted, the Veteran did not experience the kind of issues contemplated by a total rating, such as memory loss so severe that the Veteran forgets his own name. The Veteran was generally able to perform activities of daily living, and enjoyed quality time with his son, exercising at the gym, and listening to music. Although he reported periods of unemployment, he was working at the time of the last VA contract examination. In sum, the evidence supports an initial evaluation of 70 percent, and no higher, for the Veteran’s PTSD throughout the appeal period. REASONS FOR REMAND 1. Entitlement to service connection for sleep apnea is remanded. 2. Entitlement to service connection for chest pain is remanded. 3. Entitlement to service connection for back disability is remanded. The Board cannot make a fully-informed decision on the issue of entitlement to service connection because no VA examiner has opined whether the Veteran has a diagnosis of sleep apnea related to service. The Veteran asserts that he experiences sleep apnea symptoms, and that such symptoms began during service. See August 2008 Claim. He reports that he has had serious issues with sleeping since deployment to the Persian Gulf War, that his snoring is worse, that he stops breathing in his sleep, and that he gasps for air. See August 2010 Claim. He also asserts that his condition is related to environmental hazards, including heat and high dust, from his service in the Persian Gulf War. See August 2008 Claim. Medical records are conflicting regarding whether the Veteran has a diagnosis of sleep apnea. See June 2014 VA PTSD Examination Report (noting Veteran recently requested a sleep study but showed no signs of sleep apnea and that current sleep issues are related to his PTSD symptoms); December 2013 VA Treatment Record (notes the Veteran awakens from sleep gasping for air and may have sleep apnea); November 2010 VA Treatment Record (notes diagnosis of unspecified sleep apnea and symptoms of snoring, daytime sleepiness, and observed breathing stoppages). Accordingly, remand is appropriate to obtain VA medical opinion. In accordance with the September 2017 Board remand, the Veteran underwent VA contract examination in relation to his claim for service connection for chest pain in March 2018. The VA contract examiner noted a normal October 2012 electrocardiogram (EKG), but also noted that the Veteran’s online portal shows a more recent abnormal EKG and that further cardiology work-up was necessary for a more specific cause of the Veteran’s chest pain. The VA contract examiner opined that the Veteran has chronic issues with recurrent chest pain related to the chest pain experienced in 2010 and 2011 during his periods of INACDUTRA. However, the VA contract examiner noted that the cause of the chest pain was unknown and did not opine as to whether the Veteran’s chronic chest pain constituted an undiagnosed illness associated with the Veteran’s service in the Persian Gulf War. Accordingly, remand is appropriate for further VA medical opinion. As to a back disability, the Veteran reported that he injured his back when he was moving heavy boxes of mobility equipment with the supply squadron while serving with the Air Force National Guard on April 24, 2010. He reported that he felt pain in his back, and that he was evaluated and prescribed light duty. He reported that he continues to experience the same pain. A June 2014 VA examiner noted a diagnosis of lumbosacral strain. The record does not show the Veteran’s status at the time of his reported injury in April 2010, and remand is appropriate for such development. Remand is also appropriate for VA medical opinion regarding any link to service. While this matter is on remand, outstanding private and VA treatment records should be obtained, including records from Dr. Golesorkhi, including the Veteran’s EKG results, and any VA treatment records from November 2015 to the present. 4. Entitlement to a TDIU is remanded. The Veteran’s claims file shows that he has experienced periods of unemployment during the appeal period. The Veteran reported that he lost jobs due to the effects of PTSD, including problems interacting with his co-workers. See, e.g., November 2013 VA Treatment Record. As the issue of TDIU has been raised and not adjudicated by the RO, remand is appropriate for development and adjudication of the issue. The matter is REMANDED for the following action: 1. Conduct appropriate development to determine the Veteran’s status at the time of the reported April 24, 2010 incident along with any relevant records. 2. After securing any necessary authorization, obtain any private treatment records as the Veteran may identify relevant to his claims, to include any additional treatment records from Dr. Golesorkhi, including the Veteran’s EKG results. 3. Obtain additional VA treatment records from November 2015 to the present. 4. Provide a VA Form 21-8940 to the Veteran and ask him to provide information for any part of the appeal period (beginning August 2010) for which he seeks TDIU. Ask the Veteran to provide IRS tax returns for such period along with a statement that the copy is an exact duplicate of the return filed with the IRS. Provide the Veteran with an IRS Form 4506-T “Request for Transcript of Tax Return” which may also be found at https://www.irs.gov/pub/irs-pdf/f4506t.pdf so that the Veteran may request tax returns and submit them to VA. Tell the Veteran that if he does not have copies of his tax returns for the requested years, he may use the IRS form cited to above. He should submit tax records for the years he claims he is unable to obtain and maintain substantially gainful employment. 5. After obtaining any outstanding records, ask the appropriate examiner to review the Veteran’s file. The necessity of an in-person examination, with any appropriate testing, is left to the discretion of the examiner. The examiner should identify any current sleep disability the Veteran has presented during the claim period (from August 2010 to the present). For each diagnosis, opine whether it is at least as likely as not (50 percent probability or greater) that the diagnosis: (a) had its onset during active duty service from August 2002 to August 2006; or (b) is otherwise related to any injury, event, or disease during the Veteran’s active duty service from August 2002 to August 2006. If there is no diagnosed disability that the Veteran’s symptoms can be attributed to, the examiner should state whether it is at least as likely as not (50 percent probability or greater) that the symptoms represent an objective indication of chronic disability resulting from an undiagnosed illness or a medically unexplained chronic multi-symptom illness related to the Veteran’s Persian Gulf War service. The examiner should consider all medical and lay evidence of record. The Veteran reported that he has had serious issues with sleeping since deployment to the Persian Gulf War, that his snoring is worse, that he stops breathing in his sleep, and that he gasps for air. He also asserts a sleep apnea condition related to environmental hazards, including heat and high dust, from his service in the Persian Gulf War. In a November 2013 statement, the Veteran’s mother reported that he wakes up gasping for air. In a May 2005 post-deployment questionnaire, the Veteran reported that he was exposed to sand and dust. A complete rationale should be given for all opinions and conclusions expressed. 6. After obtaining any outstanding records, ask the appropriate examiner to review the Veteran’s file. The necessity of an in-person examination, with any appropriate testing, is left to the discretion of the examiner. Identify all disabilities relating to chest pain found to be present at any time since August 2010. For each diagnosis, opine whether it is at least as likely as not (50 percent probability or greater) that the disability is related to any injury, event, or disease during the Veteran’s active duty service from August 2002 to August 2006. If there is no diagnosed disability that the Veteran’s symptoms can be attributed to, the examiner should state whether it is at least as likely as not (50 percent probability or greater) that the symptoms represent an objective indication of chronic disability resulting from an undiagnosed illness or a medically unexplained chronic multi-symptom illness related to the Veteran’s Persian Gulf War service. In addition, opine as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s disability is from an injury incurred or aggravated during the Veteran’s periods of INACDUTRA in August 2010 and May 2011 or from acute myocardial infarction, cardiac arrest, or cerebrovascular accident during such periods. The examiner should consider all medical and lay evidence of record. In a May 2005 post-deployment questionnaire, the Veteran reported that he was exposed to sand and dust. A complete rationale should be given for all opinions and conclusions expressed. 7. After obtaining any outstanding records, and in accordance with the findings regarding the Veteran’s status on April 24, 2010, ask the appropriate examiner to review the Veteran’s file. The necessity of an in-person examination, with any appropriate testing, is left to the discretion of the examiner. Identify any current back disability the Veteran has presented during the claim period (from August 2010 to the present). For each diagnosis, opine whether it is at least as likely as not (50 percent probability or greater) that the diagnosis: (a) had its onset during active duty service from August 2002 to August 2006; or (b) is otherwise related to any injury, event, or disease during the Veteran’s active duty service from August 2002 to August 2006. If there is no diagnosed disability that the Veteran’s symptoms can be attributed to, the examiner should state whether it is at least as likely as not (50 percent probability or greater) that the symptoms represent an objective indication of chronic disability resulting from an undiagnosed illness or a medically unexplained chronic multi-symptom illness related to the Veteran’s Persian Gulf War service. In addition, if the Veteran’s April 24, 2010, service was during a period of INACDUTRA, opine as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s back disability is from an injury incurred or aggravated during such period. If the Veteran’s April 24, 2010 service was during a period of ACDUTRA, opine as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s back disability had its onset during the period of ACDUTRA, or is from an injury incurred or aggravated during such period. The examiner should consider all medical and lay evidence of record. The Veteran reported that he injured his back when he was moving heavy boxes of mobility equipment with the supply squadron while serving with the Air Force National Guard on April 24, 2010. He reported that he felt pain in his back, and that he was evaluated and prescribed light duty. He reported that he continues to experience the same pain. A June 2014 VA examiner noted a diagnosis of lumbosacral strain. A July 2005 STR notes low back pain for the past month with ache and pressure on the left side. A September 2002 STR notes minor musculoskeletal pains. In a May 2005 post-deployment questionnaire, the Veteran reported that he was exposed to sand and dust. The examiner should set forth the complete rationale for all opinions. 8. After the above development, and any other development deemed necessary, readjudicate the claims, including the claim for TDIU. If the benefits sought on appeal remain denied, the Veteran should be furnished a supplemental statement of the case and given the opportunity to respond thereto. MARJORIE A. AUER Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Purcell, Associate Counsel