Citation Nr: 18151877 Decision Date: 11/20/18 Archive Date: 11/20/18 DOCKET NO. 14-15 939 DATE: November 20, 2018 ORDER Entitlement to service connection for sleep apnea, to include as secondary to posttraumatic stress disorder (PTSD), is denied. Entitlement to compensation under 38 U.S.C. § 1151 for cerebrovascular accident (CVA), resulting from January 25, 2010 and/or April 7, 2010 treatment at a VA medical facility, is denied. Entitlement to an initial compensable rating for irritable bowel syndrome (IBS) prior to May 18, 2017, is denied. Entitlement to a staged rating in excess of 30 percent for irritable bowel syndrome from May 18, 2017, is denied. Entitlement to an initial rating in excess of 30 percent for PTSD prior to May 18, 2017, is denied. Entitlement to a staged rating in excess of 50 percent for PTSD from May 18, 2017, is denied. REMANDED Entitlement to a total rating based on individual unemployability due to service connected disability (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran’s sleep apnea first developed after discharge from service, is not related to service, and is not caused or aggravated by the Veteran’s PTSD. 2. The Veteran’s CVA in April 2010 did not result from VA treatment on January 25, 2010 and/or April 7, 2010, and the CVA was not due to, or a result of, a failure to diagnose on the part of the VA providers on those dates. 3. From August 23, 2010 to May 18, 2017, the Veteran’s VA treatment records showed no complaints of current gastrointestinal distress and contain many denials of any abdominal distress. 4. From May 18, 2017, the Veteran has been assigned the maximum rating available for irritable bowel syndrome. He is not entitled to a higher rating under any other applicable diagnostic code as his gastrointestinal disability has not caused colitis, adhesions, anemia, malnutrition or any other symptoms productive of severe impairment of health. 5. Prior to May 18, 2017, the Veteran’s psychiatric symptoms had been characterized by anxiety, depression, and sleep disturbances. The Veteran’s disability picture had not been manifested by 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; or difficulty in establishing and maintaining effective work and social relationships. 6. From May 18, 2017, the Veteran’s PTSD is manifested by sleep impairment, irritability, hypervigilance, low motivation, anxiety and depressed mood. The Veteran’s disability picture had not been manifested by obsessional rituals which interfered 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; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances; or an inability to establish and maintain effective relationships. CONCLUSIONS OF LAW 1. The criteria for service connection for sleep apnea, including as secondary to PTSD, have not been met. 38 U.S.C. § 1110 (2012); 38 C.F.R. §§ 3.303, 3.310 (2017). 2. The criteria for compensation under the provisions of 38 U.S.C. § 1151 for cerebrovascular accident resulting from January 25, 2010 and/or April 7, 2010 treatment at a VA medical facility have not been met. 38 U.S.C. § 1151 (2012); 38 C.F.R. § 3.361 (2017). 3. The criteria for an initial compensable rating for irritable bowel syndrome prior to May 18, 2017, were not met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.113, 4.114, Diagnostic Code (DC) 7319 (2017). 4. The criteria for a rating in excess of 30 percent from May 18, 2017, for irritable bowel syndrome have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.113, 4.114, Diagnostic Code 7319 (2017). 5. The criteria for an initial rating in excess of 30 percent for PTSD prior to May 18, 2017, were not met. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2017). 6. The criteria for a rating in excess of 50 percent for PTSD from May 18, 2017, have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1996 to April 2006. 1. Entitlement to service connection for sleep apnea, to include as secondary to posttraumatic stress disorder. The Veteran’s claim for a sleep disorder was received in August 2010. He reported that sometimes he can sleep and sometimes he can’t. He said that he woke up throughout the night. He reported that he had been treated for his sleep disorder at VA since 2009. The Veteran asserted that his sleep disorder was directly a result of service and possibly also secondary to PTSD. The service treatment records (STRs) do not document that the Veteran ever had sleep apnea or any other sleep disorder while in service. On his Report of Medical History (RPH) for his discharge examination in February 2006, the Veteran denied frequent trouble sleeping. June 2007 VA treatment records reference that the Veteran’s spouse reported that the Veteran had periods of not breathing and loud snoring while sleeping. In November 2007, VA records indicate that a sleep study resulted in an impression of sleep apnea and the Veteran was found to have mostly arousals related to anxiety. On VA psychiatric examination in August 2010 the Veteran reported that he did not have difficulty falling asleep, but that he had trouble staying asleep due to PTSD-related nightmares and startle reactions to ambient noise. The Veteran reported minimal amounts of sleep, which contributed to typical symptoms of sleep deprivation (fatigue). When examined by VA in April 2017, the Veteran reported having difficulty falling asleep while in service. He reported excessive snoring and episodes of apnea noted by his spouse around 2006. The examiner noted that the August 2007 VA sleep study was within normal results and that multiple arousals from sleep were in association with anxiety. A sleep study in April 2017 was interpreted as revealing that the Veteran had mild obstructive sleep apnea. The VA examiner opined that the Veteran’s sleep apnea was less likely than not a result of service. In support of her opinion she noted that the STRs are silent for a diagnosis of sleep apnea. The VA examiner also opined that the Veteran’s sleep apnea is not caused by, or aggravated by, the Veteran’s service-connected PTSD. She noted that the medical literature does not show an etiological or pathophysiological link between PTSD and obstructive sleep apnea. She further noted that there was no evidence of permanent aggravation of sleep apnea based on the medical records. The Board concludes that, while the Veteran has a current diagnosis of sleep apnea, the preponderance of the evidence weighs against finding that the Veteran’s diagnosis of sleep apnea began during service or is otherwise related to an in-service injury, event, or disease. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). VA treatment records first reflect symptoms attributable to sleep apnea in June 2006, more than a year after separation from service. While the Veteran is competent to report having experienced symptoms of sleep apnea during service, the Board finds the credibility of these statements is undercut by the STRs. The STRs are silent as to complaints of, diagnosis of or treatment for sleep problems. Significantly, the Veteran denied trouble sleeping on his report of medical history when examined for discharge from service. The Board places greater probative value on the contemporaneous medical evidence which was generated during the normal course of the Veteran's military career and prior to the chance for pecuniary gain. With regard to his assertions that his sleep apnea is otherwise related to service or secondary to his service-connected PTSD, he is not competent to provide such medical opinions. The issue is medically complex, as it requires interpretation of complicated sleep testing data. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). As noted above, the Veteran was not noted to have any sleep disorder until more than a year after discharge from service. Since receipt of the Veteran’s claim for service connection for a sleep disorder in August 2010, the record confirms that the Veteran has sleep apnea. The Board recognizes that prior medical records indicate that he had some arousals from sleep related to anxiety. The Board notes that the criteria for rating PTSD includes symptoms of sleep impairment and therefore such symptoms would be included when rating the Veteran’s PTSD rather than as a separate disability entitled to service connection. The most probative evidence of record is the April 2017 VA medical examination report. The VA physician examined the Veteran and reviewed his medical history and opined that the Veteran’s current sleep apnea is unrelated to service and is not caused or aggravated by his service-connected PTSD. The VA examiner provided a rationale for her opinions which is supported by citations to pertinent evidence. There are no medical opinions to the contrary. Accordingly, the Board finds that the preponderance of the evidence is against the Veteran’s claim and service connection for sleep apnea is not warranted. 2. Entitlement to compensation under 38 U.S.C. § 1151 for cerebrovascular accident resulting from treatment at a VA medical facility. The Veteran claims that he is entitled to compensation for residuals of a massive stroke he experienced on April 10, 2010. He reports that he received VA treatment on January 25, 2010, and again on April 7, 2010. He asserts that he had had mini-strokes in the past and that the VA clinicians who examined him in January 25 and April 7, 2010 were negligent because they didn’t recognize that the Veteran would soon have a stroke and take preventive action. He maintains that, given his history of mini-stokes, and the symptoms he presented when he went for treatment at VA in January and April 2010, the VA clinicians should have known that he was likely to have a massive stroke. He further asserts that if he had been appropriately treated the stroke would not have occurred. Compensation shall be awarded for a qualifying additional disability or a qualifying death of a veteran in the same manner as if such additional disability or death were service-connected. For purposes of this section, a disability or death is a qualifying additional disability or qualifying death if the disability or death was not the result of the veteran’s willful misconduct and the disability or death was caused by hospital care, medical or surgical treatment, or examination furnished the veteran under any law administered by the Secretary, either by a Department employee or in a Department facility. In addition, the proximate cause of the disability or death must be either carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of the Department in furnishing the hospital care, medical or surgical treatment, or examination; or an event not reasonably foreseeable. 38 U.S.C. § 1151. Pursuant to 38 U.S.C. § 1151, entitlement to benefits based on the failure to diagnose a preexisting condition requires a determination that: (1) VA failed to diagnose or treat a preexisting disease or injury; (2) a physician exercising the degree of skill and care ordinarily required of the medical profession reasonably should have diagnosed the condition and rendered treatment; and (3) the Veteran suffered a disability that probably would have been avoided if the proper diagnosis and treatment had been rendered. Hospital care or medical or surgical treatment cannot cause the continuance or natural progress of a disease or injury for which the care or treatment was furnished unless VA’s failure to timely diagnose and properly treat the disease or injury proximately caused the continuance or natural progress. 38 C.F.R. § 3.361(c)(2). In a claim based on an alleged failure to diagnose, “a claimant cannot demonstrate an injury unless it is shown that VA should have diagnosed the condition in question. Upon successfully demonstrating an injury or aggravation, a claimant must then prove that the injury or aggravation, that is, the failure to diagnose, resulted in additional disability or death.” Roberson v. Shinseki, 22 Vet. App. 358, 363 (2009) aff’d Roberson v. Shinseki, 607 F.3d 809 (2010). In other words, in order to prove a claim under 38 U.S.C. § 1151 for failure to diagnose, the evidence must show the three elements set forth in the preceding paragraph. See Roberson v. Shinseki, 607 F.3d 809, 817 (2010) (upholding the General Counsel’s elements of a claim based on a failure to treat); VAOPGCPREC 05-01; see also 38 C.F.R. § 19.5 (stating that the Board is bound by precedent opinions of the VA’s General Counsel). In March 2014, a VA physician opined that the Veteran’s cerebrovascular accident was unlikely to be related to the April 7, 2010, VA medical treatment. He noted that the Veteran was seen at the primary care clinic on April 7 for a follow up visit. The records indicate that all the Veteran’s conditions were stable except IBS and foot pain. He further noted that a system review specifically noted that the Veteran had no new psychiatric or neurological complaints, except as noted (PTSD). The Veteran stated that on April 9, 2010, he had a severe headache around 7:00 PM and went to bed. He woke up the next morning with slurred speech and weakness of the left extremities. He went to a private hospital and was diagnosed with a large intra-axial acute hemorrhage and a right subarachnoid hemorrhage. The VA physician stated that there was no reason to believe that the hemorrhagic stroke started prior to April 9, 2010. It was his opinion that the VA primary care provider met the standard of care during the encounter on April 7, 2010. The Veteran’s records were reviewed by another VA physician in November 2017. The VA physician opined that it was less likely than not that the Veteran’s cerebrovascular accident was a result of VA treatment, including failure to timely diagnose and appropriately treat the Veteran on January 25, 2010 and April 7, 2010. She noted that her opinion was supported by the April 7, 2010, VA records showing non-focal neurological examination, by an EMS report from April 10, 2010 where the wife reported that the Veteran had been normal when going to bed and then he woke up in the morning with neurological symptoms, and by the CNS imaging on April 10, 2010 showing acute hemorrhagic CVA. The Veteran had an acute CVA with no evidence to suggest that this condition was present at the time when the Veteran was seen by the primary care provider on April 7, 2010. The VA physician then opined that there was no evidence to suggest that any VA health professional on January 25, 2010, and/or April 7, 2010, failed to exercise the degree of care that would be expected of a reasonable health care provider. She stated that the medical records document the Veteran receiving appropriate medical evaluations, follow up and medical care. She opined that there was no evidence of carelessness, negligence, or lack of proper skill, error in judgment, or similar instance of fault on the part of VA. In assessing the claim, the Board has considered the Veteran’s lay assertions that he incurred a CVA due to failure of VA medical professionals to provide him proper preventative care. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue here, whether the VA providers should have known that the Veteran would soon have a CVA, such falls outside the realm of common knowledge of a lay person as this is beyond the capability of a lay person to observe. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). Rather, it requires specialized knowledge of medical principles relating to the neurological system. The Board places greater probative weight on the findings of the health care professionals who opined that there was no fault on the part of the VA providers who treated the Veteran on January 25, 2010 and April 7, 2010. The medical evidence of record reflects that the Veteran received proper care at VA and that there was no failure to diagnose or provide preventative treatment. The Board finds that the criteria for entitlement to compensation under the provisions of 38 U.S.C. § 1151 for cerebrovascular accident claimed as due to January 25, 2010 and/or April 7, 2010 VA treatment or as the result of failure to diagnose have not been met, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Increased Rating 3. Entitlement to an initial compensable rating for irritable bowel syndrome prior to May 18, 2017. The February 2012 rating decision on appeal granted service connection for irritable bowel syndrome and assigned a noncompensable rating effective from August 23, 2010. The Veteran appealed the noncompensable rating assigned. He reported that he had flare-ups where he could not eat and that what went in came right back out. He stated that during flare-ups he lost a lot of weight. Rating for the digestive system are found at 38 C.F.R. § 4.114. The instructive paragraph before the rating table states: “Ratings under diagnostic codes 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348 inclusive will not be combined with each other. A single evaluation will be assigned under the diagnostic code which reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation.” A review of the evidence indicates that the Veteran’s IBS has been determined to be the predominant digestive disability. Under Diagnostic Code 7319, the rating code for irritable colon syndrome, a non-compensable rating is warranted for mild symptoms such as disturbances of bowel function with occasional episodes of abdominal distress. A 10 percent rating is warranted for moderate symptoms such as frequent episodes of bowel disturbance with abdominal distress. A 30 percent rating is warranted for severe symptoms such as diarrhea or alternating diarrhea and constipation with more or less constant abdominal distress. 38 C.F.R. § 4.114, Diagnostic Code 7319. On VA examination in December 2011, the examiner noted that, in the past, the Veteran had had gastroenteritis that resulted in the loss of 60 pounds and in his being hospitalized several times. The examiner noted that the problem had resolved by the end of 2009. The examiner noted that the Veteran did not have any current esophageal symptoms. When provided another VA examination, in March 2014, the Veteran reported chronic diarrhea. Physical examination was normal. A review of the VA treatment records shows that the Veteran has not met the criteria for a compensable rating for his gastrointestinal disorder at any time prior to May 18, 2017. Although the VA treatment records show treatment for significant gastrointestinal symptoms early in 2010, such symptoms had resolved prior to the grant of service connection. During the appeal period, between August 2010 to May 2017, the record shows no treatment for gastrointestinal symptoms and it contains many records reporting that the Veteran specifically denied abdominal pain. These records also do not indicate that the Veteran experienced chronic diarrhea between August 2010 and May 2017. During the appeal period prior to May 18, 2017, the Veteran did not meet the criteria for a compensable rating under DC 7319, or any other applicable diagnostic code, due to gastrointestinal symptoms. Accordingly, an initial compensable rating for a gastrointestinal disorder at any time prior to May 18, 2017 is not warranted. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). 4. Entitlement to a staged rating in excess of 30 percent for irritable bowel syndrome from May 18, 2017. A November 2017 rating decision granted the Veteran a staged rating of 30 percent for irritable bowel syndrome from May 18, 2017. The Board finds that the criteria for a rating in excess of 30 percent for IBS have not been met at any time during the appeal period. The Board notes that the current 30 percent rating is highest available schedular rating available under Diagnostic Code 7319. As such, the Board will consider if the criteria for a higher rating have been met under any other applicable Diagnostic Code. The May 18, 2017 VA examination report indicated that the Veteran reported frequent episodes of diarrhea and abdominal pain. He also reported weight loss. The report reveals that the Veteran was not taking any medication to treat his symptoms. The examiner found that the Veteran had no malnutrition, serious complications or other general health effects attributable to the intestinal condition and that it did not impact his ability to work. A rating of 50 percent could potentially be assigned under Diagnostic Code 7301 (adhesions) for definite partial obstruction shown by X-ray and frequent and prolonged episodes of severe colic distention, nausea or vomiting. A rating of 60 percent could potentially be assigned under Diagnostic Code 7307 (gastritis) for severe hemorrhages or large ulcerated or eroded areas. A rating of 60 percent could potentially be assigned under Diagnostic Code 7323 (colitis) for severe ulcerative colitis with numerous attacks a year and malnutrition. Finally, a rating of 60 percent could potentially be assigned under Diagnostic Code 7346 (gastroesophageal reflux disease) for symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia or for other symptom combinations productive of severe impairment of health. 38 C.F.R. § 4.114, Diagnostic Codes 7301, 7307, 7323, 7346 (2017). However, throughout the entire appellate period, there is no objective or subjective evidence that the Veteran’s overall disability picture approximates any of these rating criteria. A review of the relevant treatment records and examination reports show that the Veteran has complained of diarrhea, abdominal pain and some weight loss. However, there was no diagnosis of, or evidence suggestive of, colitis, adhesions, anemia, or malnutrition. Although weight loss was noted, none of the other criteria for a 60 percent rating under DC 7346 were noted and the VA examiner specifically found that the Veteran’s IBS symptoms did not cause severe impairment of health, which is a requirement for a 60 percent rating under DC 7346. As shown above, the Board has considered the Veteran’s disability under other pertinent criteria, but finds that there are no other rating codes which either provide for an evaluation higher than the currently assigned 30 percent rating, or are appropriate for rating the Veteran’s IBS. Accordingly, the preponderance of the evidence is against the Veteran’s claim and entitlement to a rating in excess of 30 percent for irritable bowel syndrome is not warranted. 5. Entitlement to an initial rating in excess of 30 percent for PTSD prior to May 18, 2017. The May 2011 rating decision on appeal granted the Veteran service connection for PTSD. The Veteran was assigned a 30 percent rating effective from February 25, 2010. The Veteran appealed the 30 percent rating assigned. Prior ot May 18, 2017, the Veteran’s PTSD has been evaluated as 30 percent disabling pursuant to the criteria set out in 38 C.F.R. § 4.130, Diagnostic Code 9411. A 30 percent evaluation is warranted for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 50 percent disability evaluation encompasses post-traumatic stress disorder manifested by 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). A 70 percent rating contemplates occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. A 100 percent rating contemplates 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. 38 C.F.R. § 4.130, Diagnostic Code 9411. On VA examination in August 2010, the Veteran reported difficulty staying asleep due to PTSD-related nightmares and startle reactions to ambient noise. He also reported mood swings and irritability. The VA examiner noted that the Veteran was able to form and maintain close relationships. He was clean, neatly groomed and appropriately dressed. The Veteran was cooperative, friendly, relaxed and attentive. He denied panic attacks, homicidal thoughts or suicidal thoughts. The examiner opined that there was no reduced reliability and productivity due to PTSD symptoms. He also noted that the Veteran’s PTSD symptoms did not decrease work efficiency or impair the ability to perform occupational tasks. The VA treatment records dated between February 2010 and May 18, 2017, show that the Veteran denied any suicidal or homicidal ideation. He was also noted to have intact recent and remote memory. His affect and mood were noted to be fair and his judgment was noted to be intact. The evidence between February 2010 and May 18, 2017 clearly shows that the Veteran has not had 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; or any other of the symptoms indicative of a 50 percent rating for PTSD or higher. Accordingly, an initial rating in excess of 30 percent is not warranted at any time prior to May 18, 2017. See Fenderson. 6. Entitlement to a stage rating in excess of 50 percent for PTSD from May 18, 2017. A November 2017 rating decision assigned the Veteran a staged rating of 50 percent for PTSD from May 18, 2017. As explained below, the Board finds that the criteria for a rating in excess of 50 percent for PTSD have not been met. On VA examination on May 18, 2017, the VA examiner opined that the Veteran’s PTSD resulted in occupational and social impairment with reduced reliability and productivity. The Veteran reported that he was working 25 hours a week at a nonprofit through Access 2 Independence. The Veteran’s symptoms were noted to be depressed mood, anxiety, suspiciousness, panic attacks that occur weekly or less often, chronic sleep impairment, mild memory loss, and disturbances of motivation and mood. The Veteran was fully cooperative, but with some ataxia and hearing problems secondary to stroke. He was fully capable of managing his financial affairs. In June 2017 the VA examiner added that the Veteran has significant residual overlapping symptoms from his PTSD and major depressive disorder such that he was not sleeping and was socially withdrawn and hypervigilant. He still had dreams/memories and flashbacks of his combat tour. The examiner noted that the Veteran experienced irritability/hypervigilance connected to PTSD, with low mood and low motivation. She noted that the Veteran’s medical condition and residuals of stroke were further exacerbating the Veteran’s psychiatric symptoms. VA treatment records subsequent to May 18, 2017, note that the Veteran had increased irritability. His appearance was neat and his memory appeared good. One time he described his mood as “okay” and another time he described his mood as “pretty good.” His judgment and insight were noted to be fair. The Veteran denied suicidal and homicidal ideation. The medical records clearly show that the Veteran has not had such symptoms as obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and inability to establish and maintain effective relationships; or symptoms of a similar nature and severity or greater. Accordingly, the Board finds that the Veteran was not shown to meet the criteria for a rating in excess of 50 percent for PTSD at any time since the grant of service connection. REASONS FOR REMAND 1. Entitlement to a total rating based on individual unemployability due to service connected disability (TDIU). The Veteran’s claim for TDIU was remanded in March 2016 in order to obtain a medical opinion fully describing the functional effects of the Veteran’s combined service-connected disabilities on his ability to perform the activities of daily living, to include the mental and physical acts required for gainful employment. On remand the requested opinion was not obtained. Accordingly, the TDIU claim must be remanded for corrective action. See Stegall v. West, 11 Vet. App. 268 (1998). The matter is REMANDED for the following action: 1. Obtain the Veteran’s updated VA treatment records to the extent possible. 2. When the above action has been completed, provide the Veteran an appropriate medical examination. The examiner should fully describe the functional effects of each of the Veteran’s service-connected disabilities to include the mental or physical acts required for gainful employment. The examiner should also discuss the combined effects of the Veteran’s service-connected disabilities on his ability to perform the mental and physical acts required for gainful employment. The examiner should refrain providing an opinion on whether the Veteran is actually employable or not. These disabilities are asthma, PTSD, right ear tinnitus, right ear hearing loss, residuals of a skin rash of the arms, neck and upper back, chronic dermatitis of the left wrist dorsum and a gastrointestinal condition on his ability to perform the activities of daily living. If the Veteran fails to report for the examination the VA examiner should provide the requested opinions based on a review of the Veteran’s claims file. G. A. WASIK Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD R. E. Jones, Counsel