Citation Nr: 18141018 Decision Date: 10/09/18 Archive Date: 10/09/18 DOCKET NO. 16-22 317 DATE: October 9, 2018 REMANDED Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty in the Army from March 1970 to November 1971. He is a recipient of the Combat Infantryman Badge and the Vietnam Service Medal with one bronze star. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a May 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina (Agency of Original Jurisdiction (AOJ)). 1. Entitlement to TDIU is remanded. The Veteran is presently service connected for residuals of post traumatic brain injury (TBI) to include headaches and dizzy spells, rated as 70 percent disabling; posttraumatic stress disorder (PTSD), rated as 30 percent disabling; scar, right mastoid area with retained foreign bodies (shrapnel) as residual of shell fragment wound, rated as 10 percent disabling; tinnitus, rated as 10 percent disabling; and right thigh muscle group XIII shell fragment wound with soft tissue metallic foreign body, rated as 10 percent disabling. The Veteran is also service-connected for scars, right arm as residual of shell fragment wound; scar, right side of chest as residual of shell fragment wound; and scar, right thigh as residual of shell fragment wound; each of these disabilities are rated as non-compensable. As the Veteran’s disabilities combine to at least a 70 percent disability rating with one disability rated higher than 40 percent, the Veteran meets the schedular requirements for eligibility for a TDIU rating. 38 C.F.R. §§ 4.16, 4.18 (2017). However, the Board seeks more contemporaneous VA examinations for the Veteran’s claim for TDIU. The last examination for the Veteran’s PTSD was conducted in April 2014, while the last examination for his scars took place in July 2014. The most recent examinations for his TBI and tinnitus subsequently occurred in August 2014. The Veteran contends that he has been unable to work since April 2006, which coincides with when he had a stroke. It should be noted that a VA examination from April 2011 indicated that the Veteran “is not employable and received social security disability as a result of his physical impairments that occurred when he had a stroke in 2006.” The Board makes note of the fact that the Veteran’s TBI disability rating has fluctuated over the recent years, indicating a fluid level of disability. Following an August 2009 VA examination, the Veteran’s disability rating for TBI was increased from 10 percent to 70 percent. Thereafter, it was decreased to 40 percent after a March 2010 VA examination indicated improvement, and once again increased to 70 percent in a November 2014 rating decision. As the most recent examination for his highest-rated disability was conducted more than four years ago and given that it has been subject to fluctuating disability ratings, the Board finds that a remand is warranted to obtain examinations to determine the extent to which his service-connected disabilities, notably his TBI and PTSD, impact his ability to obtain and maintain substantially gainful employment. The matter is REMANDED for the following action: 1. Obtain and associate with the claims folder updated VA treatment records and any private treatment records, specifically those from January 2016 to present. 2. Thereafter, afford the Veteran an examination to determine the current severity of his post-TBI residuals. The examiner is specifically asked to form an opinion regarding the extent to which this condition affects the Veteran’s ability to obtain and maintain substantially gainful employment. The examiner should undertake a longitudinal review of the VA examinations from August 2009 to present and identify the workplace limitations caused by post-TBI residuals since February 2011. The examiner should specifically delineate any symptoms of stroke residuals from post-TBI residuals. If any symptoms cannot clearly be delineated, the examiner should attribute those symptoms to post-TBI residuals. 3. Afford the Veteran an examination to determine the current severity of his PTSD. The examiner is specifically asked to form an opinion regarding the extent to which this condition affects the Veteran’s ability to obtain and maintain substantially gainful employment since February 2011. The examiner should specifically delineate any symptoms of stroke residuals from PTSD. If any symptoms cannot clearly be delineated, the examiner should attribute those symptoms to PTSD. 4. Afford the Veteran an examination to determine the current severity of his scars. The examiner is specifically asked to identify the workplace limitations caused by tinnitus since February 2011. 5. Afford the Veteran an examination to determine the current severity of his tinnitus. The examiner is specifically asked to identify the workplace limitations caused by tinnitus since February 2011. 6. Thereafter, readjudicate the claims. If any benefit sought on appeal remains denied, furnish the Veteran and his representative a supplemental statement of the case and an appropriate period of time to respond. T. MAINELLI Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Victoria A. Narducci, Associate Counsel