Citation Nr: 18157695 Decision Date: 12/13/18 Archive Date: 12/13/18 DOCKET NO. 14-21 698 DATE: December 13, 2018 ORDER The withdrawn claim of entitlement to an increased rating disability for degenerative arthritis of the right shoulder is dismissed. The withdrawn claim of entitlement to service connection for hypertension is dismissed. Entitlement to a rating in excess of 70 percent for posttraumatic stress disorder (PTSD) is granted. Entitlement to a total disability rating based on individual unemployability (TDIU) is granted. REMANDED Entitlement to service connection for a sinus condition is remanded. Entitlement to service connection for headaches, to include as secondary to a sinus condition is remanded. FINDINGS OF FACT 1. The Veteran withdrew his claim for entitlement to an increased rating for degenerative arthritis of the right shoulder in November 2018 correspondence. 2. The Veteran withdrew his claim for entitlement to service connection for hypertension in November 2018 correspondence. 3. During the appeals period, the Veteran’s acquired psychiatric disorder manifested as occupational and social impairment with deficiencies in most areas. 4. During the appeals period, The Veteran’s service-connected chronic acquired psychiatric disorder precludes him from securing or following substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for withdrawal of the claim for entitlement to an increased rating for degenerative arthritis of the right shoulder have been met. 38 U.S.C. § 7105 (2014); 38 C.F.R. § 20.204 (2018). 2. The criteria for withdrawal of the claim for entitlement to service connection for hypertension have been met. 38 U.S.C. § 7105 (2014); 38 C.F.R. § 20.204 (2018). 3. The criteria for a 70 percent disability rating for PTSD have been met. 38 U.S.C. §§ 1155, 5107 (2014); 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.130, Diagnostic Code (DC) 9411, General Rating Formula for Mental Disorders (2018). 4. The criteria for a TDIU have been satisfied. 38 U.S.C. §§ 1155, 1507, 5110, 7105 (2014); 38 C.F.R. § 3.400, 4.16 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 1970 to October 1971, to include service in the Republic of Vietnam. This case comes before the Board of Veterans’ Appeals (Board) from a rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The Board acknowledges the Veteran’s attempt to withdraw his service connection claim for a skin disorder of the bilateral feet in November 2018 correspondence. However, as the Veteran did not file VA Form 9 as to this issue, the Board does not have jurisdiction over this claim. Withdrawn Claims The Board may dismiss any appeal that fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C. § 7105 (West 2014). An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 20.204 (2018). Withdrawal may be made by the Veteran or by his or her authorized representative. Id. In November 2018 correspondence, the Veteran stated that notified he wished to withdraw his increased rating claim for degenerative arthritis of the right shoulder, as well as his service connection claim for hypertension. These withdrawals are in writing and have been associated with the Veteran’s claims file. There remain no allegations of errors of fact or law for appellate consideration. The Board does not have jurisdiction to review these claims, and they are therefore dismissed. 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. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.1 (2018). The basis of disability ratings is the ability of the body as a whole, or of the psyche, or of a system or organ of the body, to function under the ordinary conditions of daily life, including employment. 38 C.F.R. § 4.10 (2018). The determination of whether an increased rating is warranted is based on review of the entire evidence of record and the application of all pertinent regulations. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two ratings shall be applied, the higher rating 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 (2018). However, the evaluation of the same disability under various diagnoses, known as pyramiding, is to be avoided. 38 C.F.R. § 4.14 (2018). While the Veteran's entire history is reviewed when making a disability determination, where service connection has already been established and increase in the disability rating is at issue, it is the present level of the disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). However, staged ratings are appropriate for an increase rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Entitlement to a rating in excess of 30 percent for PTSD The Veteran contends that his service-connected PTSD warrants a higher rating. When rating a mental disorder, VA must consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the claimant’s capacity for adjustment during periods of remission. VA shall assign a rating 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. 38 C.F.R. § 4.126 (a) (2018). When rating the level of disability from a mental disorder, VA will consider the extent of social impairment, but shall not assign a rating solely on the basis of social impairment. 38 C.F.R. § 4.126 (b) (2018). The Veteran’s PTSD is currently rated as 30 percent disabling under DC 9411. Under the General Rating Formula for Mental Disorders, a 30 percent disability 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 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). Id. 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 per 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 assigned for 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. Id. A 100 percent rating is assigned 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 symptoms listed in the rating formula are examples, not an exhaustive list. Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002) (finding that “any suggestion that the Board was required . . . to find the presence of all, most, or even some of the enumerated symptoms is unsupported by a reading of the plain language of the regulation”). However, “a Veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration.” Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013). “The regulation’ plain language highlights its symptom-driven nature” and “symptomatology should be . . . the primary focus when deciding entitlement to a given disability rating.” Id. at 116-17. As such, 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 to the extent specified in the rating criteria; rather than solely on the examiner's assessment of the level of disability at the moment of examination. See 38 C.F.R. § 4.126 (a). Upon review of the record, the Board finds that a disability rating in excess of 30 percent for the Veteran’s service-connected PTSD is warranted. Turning to the evidence of record, in an undated 2010 statement, the Veteran’s ex-wife (J.D.) stated that the Veteran had nightmares all of the time and would wake up yelling, sweating, anxious, and inconsolable. She also stated that the Veteran was “closed off” regarding his war experiences, embarrassed about his ability to control his thoughts and memories, and suffered immense guilt about having survived. She further noted that the Veteran had an inability to bond with his daughter, totaled five cars, and was in a number or barroom brawls during their marriage. She stated that the fights were provoked by comments about his participation in the war and in his appearance. In a July 2010 statement, she noted that the Veteran’s frustration was displayed with bouts of unjustified anger, suspicion, and depression. The Veteran was afforded a VA examination in December 2010. The Veteran noted sleep disturbances, to include one nightmare per week. The examiner noted auditory hallucinations, but stated that they did not occur on a persistent basis. The Veteran did not have obsessive behavior. The Veteran also stated that he works to distract his thoughts. He noted that he used to have a lot of friends in the past and that he avoids crowds and always feels “on edge.” He also stated that he wanted to be in one of two places: in the house or in the tavern drinking. The Veteran also stated that he was unable to “have a decent relationship with a woman” and attributed this to his lack of interest in doing things. The Veteran had panic attacks in the past, with the last occurrence three to four years ago. The Veteran denied homicidal and suicidal thoughts. The Veteran’s impulse control was deemed fair with noted episodes of violence, particularly when drinking. The Veteran was able to maintain minimum personal hygiene and there was no problem with activities of daily living. The Veteran’s remote memory was normal and his recent memory and immediate memory were mildly impaired. Additional symptoms associated with his PTSD included recurrent and intrusive distressing recollections of the event; efforts to avoid thoughts, feelings, or conversations associated with trauma; irritability or outbursts of anger; and hypervigilance. The Veteran’s symptoms occurred on a weekly basis and were mild in severity. The examiner opined that the Veteran’s social and persistent occupational functioning was minimally impaired by his PTSD symptoms. In an April 2014 statement, the Veteran’s girlfriend (C.F.) stated that the Veteran lacked concentration and patience to handle the routine financial and business matters of everyday life. She also indicated that she handles his financial matters. Further, she stated that the witnessed the Veteran awaken and insist that they need to seek cover. She also reported that the Veteran has difficulty sleeping normally and that he is only calmed by alcohol consumption. She further described their relationship as “rocky” and said that she had temporarily moved out several ties and the only reason why she remained in the relationship was to better understand the Veteran’s condition. In an April 2014 NOD, the Veteran reported that he lost his job due in part to his PTSD and the difficulties that it was causing him at work. He also stated that he is often irritable with people and had angry outbursts for no reason. He further reported that he is very uncomfortable in unfamiliar settings or large groups, worries constantly to the point of near panic, has difficulty sleeping, and often has flashbacks and bad dreams. The Veteran also reported that his short- and long-term memory are bad. In a December 2015 DBQ, the examiner noted diagnoses of PTSD; Major Depressive Disorder, Recurrent Severe; and Alcohol Use Disorder, Mild. The Veteran reported that he had an unstable relationship with his long-term girlfriend and that she has moved out at least twice a year. He noted a distant relationship with his daughter due to his inability to express his feelings and be around crowds. The Veteran reported that he lost his long-term job due to his irritability, hypervigilance, and difficulty being around others; the examiner endorsed that this was the reason the Veteran was no longer employed. The Veteran stated that he was taking medication. He also stated that he made many mistakes due to concentration problems, that he isolates himself by shopping at 4 a.m. or by asking his girlfriend to run such errands. He also stated that he had not been in a restaurant in three years. He also reported that he hit his friend in the mouth and reported that he had sudden reflexes when he was approached from behind. Further, the Veteran reported that he called the police after thinking that someone was in the woods, although no one was found. The examiner stated that such was presumed to be a combat-associated hallucination. The examiner noted that the symptoms attributable to PTSD included anxiety, isolation, and concentration problems. The examiner also noted symptoms to include obsessional rituals which interfere with routine activities, neglect of personal appearance and hygiene, difficulty in adapting to stressful circumstances, and difficulty in establishing and maintaining effective work and social relationships. The examiner opined that the Veteran’s symptoms caused occupational and social impairment with deficiencies in most areas. In a December 2015 affidavit, the Veteran’s girlfriend, noted that it was normal for the Veteran to awaken and wander the house, looking out of windows and checking doors to ensure that they are locked. She also stated that while the Veteran was working, she heard of disagreements between the Veteran and various other co-workers. She stated that the Veteran had difficulty in letting go of incidents and that he repeated them multiple times at home. She also stated that she and the Veteran did not have a social life and that they stay in the house at night due to the Veteran’s disinterest in going new places or where there will be many people. She also reported that in the rare instance that they have company, invited guests do not extend beyond his daughter, her daughter and family, or grandchildren. She further noted that the Veteran does not like loud noises and has hit the ground on several occasions due to an unexpected noise. Private treatment records, dated from December 2015 to January 2016, reveal that the Veteran presented to the emergency room with passive suicidal ideation. Specifically, in a December 2015 treatment note, the Veteran reported that he had daily thoughts of suicide. A January 2016 treatment record shows that the Veteran’s hygiene was decreased. The Veteran was afforded a VA examination in January 2016. The examiner noted diagnoses of PTSD, unspecified depressive disorder, and alcohol use disorder. The examiner also stated that it was not possible to differentiate which symptoms are attributable to each diagnosis. The Veteran reported that he was hypervigilant about the security of his environment. He also stated that he has difficulty sleeping and staying asleep and experiences nightmares related to his service. The examiner noted that the Veteran was casually and appropriately dressed; that his psychomotor skills, speech, eye contact, thought processes, thought content, and memory were within appropriate limits; his affect and mood were depressed and anxious. The examiner also noted that the Veteran did not have inappropriate behavior, episodes of violence, and appeared to have the capacity to understand the outcome of his behavior, as well as the capacity to develop adequate insight. The Veteran denied homicidal and suicidal ideation. The examiner noted that the Veteran’s symptoms caused occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. A May 2016 treatment note shows that the Veteran reported chronic hopelessness and thoughts of not caring whether he was around or not. A June 2016 treatment note reveals that the Veteran reported that he continued to struggle with anxiety, depression, and PTSD, and that he continued to keep his symptoms to himself until recently. He reported recurrent nightmares, intrusive recollections, hypervigilance, frequent panic attacks, poor sleep, and depressive symptoms. He reported that he was disconnected from his family, friends, or support groups. His mood was assessed as dysthymic and dysphoric and his affect was sad and anxious. The Veteran was advised to return to the PTSD clinic for continued assessment and individual therapy, to continue taking his medications, and encouraged to reduce his alcohol use. A May 2016 treatment note reveals that the Veteran presented with unkempt hair. An August 2017 treatment note reveals that the Veteran was taking medication which was reportedly helping a lot with his mood. He also stated that he was handling his anger and irritability better. The Veteran denied racing thoughts, feelings of hopelessness, or any thoughts of harming himself or others. Considering the evidence of record, medical and lay, the Board finds that the Veteran’s psychiatric disability more nearly approximates a 70 percent rating for occupational and social impairment with suicidal ideation; the inability to establish and maintain effective relationships; and neglect of personal appearance; obsessional rituals; and difficulty in adapting to stressful circumstances. Further, the Veteran’s treatment records indicated that he experienced recurrent suicidal thoughts, to include statements that he experienced suicidal thoughts daily. The Board finds no reason to doubt the credibility of the Veteran’s lay statements regarding his suicidal ideation. Additionally, the VA examiner found that the Veteran’s psychiatric symptoms significantly impair his social and occupational functioning. Notably, the December 2015 examiner opined that the Veteran’s symptoms caused occupational and social impairment with deficiencies in most areas. The Board has considered whether a 100 percent disability rating is warranted for the Veteran’s PTSD. According to the evidence of record, the Veteran’s overall symptoms do not demonstrate total occupational and social impairment, as he does not experience persistent delusions or hallucinations, he has not acted on his suicidal and homicidal ideations, nor does he experience gross impairment in thought process, memory loss, or disorientation to time or place. Therefore, the Veteran’s psychiatric disability does not warrant a 100 percent disability. For all the forgoing reasons, and resolving all reasonable doubt in favor of the Veteran, the Board finds that a 70 percent disability rating is warranted for the Veteran’s service-connected PTSD for the entire period on appeal. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102, 4.130, DC 9411; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). While some of the symptoms experienced by the Veteran approximate those listed in the 100 percent criteria, the Board finds that, overall, his symptoms, to include suicidal ideation and the inability to establish and maintain effective relationships are of similar duration, frequency, and severity as those described for a 70 percent rating under occupational and social impairment with deficiencies in most areas. Accordingly, a disability rating of 70 percent for the Veteran’s service-connected PTSD for the entire period on appeal is granted. TDIU Total disability is considered to exist when there is any impairment which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. 3.340 (a)(1) (2018). A total disability rating for compensation purposes may be assigned on the basis of individual unemployability: that is when the disabled person is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. If there is only one service-connected disability, it must be rated 60 percent or more. 38 C.F.R. 4.16 (a) (2018). As the Board’s grant of a 70 percent rating for the Veteran’s psychiatric disorder covers the entire appeal period, the criteria for consideration of a schedular TDIU are met. Individual unemployability must be determined without regard to any nonservice-connected disabilities or the Veteran's advancing age. 38 C.F.R. 3.341 (a), 4.19 (2018); Van Hoose v. Brown, 4 Vet. App. 361(1993). When the Board conducts a TDIU analysis, it must consider the Veteran’s education, training, and work history. Pederson v. McDonald, 27 Vet. App. 276 (2015). In an April 2014 NOD, the Veteran stated that he lost his job due in part to his PTSD and the difficulties that it was causing him at work. He also stated that his right shoulder injury affected his ability to do any lifting or climbing, activities required by his former employer. In December 2015, February 2016, and June 2016, the Veteran submitted VA Forms 21-8940, Veteran’s Application for Increased Compensation Based on Unemployability. In the December 2015 application, the Veteran cited that his PTSD and right shoulder disabilities prevented him from securing or following substantially gainful occupation. He also noted that his nonservice connected chronic sinusitis prevented him from working. In the February 2016 and June 2016 applications, the Veteran identified that his PTSD prevented him from securing or following any substantially gainful employment. He stated that he left his last job due to his disability and that he had not tried to obtain employment since he became too disabled to work. He also identified, in the Remarks section, that his right shoulder made the completion of physical tasks of his former job more painful and much more difficult. The Veteran reported that he had a college degree, but did not have any additional education and training. The record reveals that the Veteran obtained a Bachelor’s degree in Business Management. The evidence of record also shows that the Veteran was deemed disabled by Social Security Administration (SSA) and that he became disabled in September 2010. His medical records have been associated with the claims file. Following discharge, the Veteran worked as a shift supervisor where he was in charge of production workers spooling recording tapes. The Veteran reported that he could not deal with the pressures of working and dealing with a shift of people and co-workers, so he quit the job after a year. The Veteran reported that he did not return to work in a steady job for several years, but instead worked in various short-term jobs. In 1977, the Veteran enrolled in an Associate’s program for Surface Mining Operations Technology, but quit the program. He then enrolled in a Master’s program for psychology, but also quit after several months once he realized that the work involved interactions with others. See November 2018 Vocational Assessment. The record further reflects that the Veteran worked as a chemical technician from June 1981 until October 2010. His duty included training new technicians, lift and/or carry heavy weights, operating water systems, checking and adjusting water levels. The Vocational Consultant stated that his position was classified as a semi-skilled to skilled occupation, which required the ability to stand or walk at least 6 hours of the workday, required occasional lifting and carrying up to 20 to 50 pounds, and required frequent handling and reaching, especially of the dominant upper extremity. In a December 2010 VA examination, the examiner opined that the Veteran’s PTSD caused clinically significant distress or impairment in social, occupational, or other important areas of functioning. A December 2010 VA joint exam reveals that the Veteran had flare-ups of his right shoulder, which was often precipitated by cold, damp weather which impacted his ability to use his right shoulder. In a February 2013 progress note, the examiner opined that the Veteran’s condition impacted his ability to work in that he could work in a sedentary or physical job that did not require repetitive lifting or pulling. A December 2013 progress note reveals that that the Veteran reported gradual worsening in constant pain over time since his initial shoulder injury and worsening range of motion over the past two years. A January 2013 VA joints examination report reveals that the Veteran’s right upper extremity condition impacts his ability to perform any occupational tasks due to the inability to bring his right dominant hand or arm back beyond 20 degrees and had limitations in forward extension, abduction, and external rotation. In an April 2014 statement, the Veteran noted that despite his academic capability, he did not have the patience of handling his day-to-day business and financial matters. He also noted that he is often irritable with people, has unprovoked anger and outbursts, and cannot control his emotions. He also cited that he worries constantly, is uncomfortable in unfamiliar settings or in large groups, and has difficulty sleeping. The December 2015 DBQ examiner opined that the Veteran lost his job due to his PTSD. The examiner also opined that the Veteran has had a significant impairment in functioning resulting in the loss of his long-term employment that appeared to be associated with the resurgence of his PTSD symptoms. The examiner opined that the Veteran’s symptoms caused occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and/or mood. The January 2016 VA PTSD examiner opined that the Veteran had occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. A June 2016 psychiatric note reveals that the Veteran had been seen for ongoing PTSD and depressive symptoms for which he had been taking medications prescribed by his private physician. The clinician noted that the Veteran had been service connected at 30 percent for PTSD since 2010 but noted that the Veteran’s symptoms had increased. A June 2018 VA joints examination reveals that the Veteran had abnormal range of motion of the right knee, as well as pain, weakness, fatigability, and incoordination. The examiner opined that the Veteran’s knee condition impacts his ability to work due to his inability to stand for prolonged periods of time. A July 2018 VA joints examination reveals that the Veteran had degenerative arthritis of the right shoulder with abnormal range of motion with pain, which impacted his ability to use his right arm. In further support of his claim, the Veteran submitted a November 2018 vocational assessment, which assessed the Veteran’s ability to work when considering his service-connected PTSD, degenerative arthritis of the right shoulder, and right knee strain. Following an interview and a review of the Veteran’s file, the consultant opined that the Veteran was considered to be vocationally disabled and has not been able to secure or perform any type of substantially gainful occupation within the general labor market since 2010. The consultant primarily relied on the affidavits of his former wife and current girlfriend, the December 2010 VA PTSD examination, the June 2016 psychiatric note noting an increase in symptoms, a December 2010 VA joint examination, a February 2013 VA joints examination, and a December 2013 progress note showing gradual worsening of shoulder pain and range of motion. The examiner also concluded that the Veteran’s vocational skills acquired in his occupation was specific to that occupation and that he lacked transferable vocational skills to alternate occupations within the labor market. The examiner also noted that unskilled work requires frequent use of the bilateral upper extremities, particularly that of the dominant upper hand/arm. The Board has also considered the affidavit and lay statements from the Veteran’s ex-wife and current girlfriend which reveal the Veteran’s ongoing issues related to working and being around people, as well as his ongoing symptoms of anger and irritability. Further, the Board acknowledges the Veteran’s girlfriend’s statements that the Veteran had difficulty with concentration and attention and lack of patience to deal with handling money and business responsibilities of daily life, despite the fact that he has a college degree in Business. The Board finds the November 2018 vocational assessment to be probative. The vocational assessment, unlike the free-standing VA opinions of record, considered all of the Veteran’s service-connected abilities as a whole. Further, the Board acknowledges that the December 2015 examiner opined that the Veteran’s psychiatric symptoms caused occupational and social impairment with deficiencies in most areas. Thus, upon review of the evidence of record, including the competent and credible lay statements provided by the Veteran, his ex-wife, and current girlfriend, along with the November 2018 consultant’s opinion, the Board finds that the Veteran’s service-connected disabilities preclude substantially gainful employment. As such, a TDIU is granted. REASONS FOR REMAND 1. Entitlement to service connection for a sinus condition is remanded. The Veteran contends that service connection is warranted for a sinus condition. Specifically, the Veteran contends that a sinus condition, septal perforation with nosebleeds, related to herbicide exposure in Vietnam. At the outset, the Board notes that VA has conceded exposure to herbicides based upon the Veteran’s service in Vietnam, as well as the onset of nosebleeds during service. The remaining question remains whether the Veteran’s complaints of nosebleeds were the early manifestation of the nasal septal perforation shown in his treatment records. The Veteran was afforded a VA examination in November 2000. The examiner stated that in the past, the Veteran had intranasal toxic exposure. The examiner also opined that it appeared likely that his septal perforation is related to his history of trauma and intranasal toxic exposure. The Veteran was also afforded a VA examination in February 2014. The examiner opined that it was less likely as not that the Veteran’s nasal septum perforation was related to his nosebleeds that began in service. The rationale provided for the opinion was that the Veteran did not have medical records indicating that he was seen in Vietnam for nosebleeds or any sinus issues and that it was at least 30 years later that he sought treatment (per his medical records). The examiner also stated that the Veteran has a nasal septum perforation, which is a separate condition. The examiner noted that the more likely etiologies are dry air, sinus conditions, and hypertension. In a November 2015 DBQ, the examiner noted diagnoses of sinusitis, rhinitis, and deviated nasal septum, with symptoms of episodes of sinusitis, near constant sinusitis with constant drainage and nosebleeds, and nasal septal perforation. No etiology opinion was noted. The Board finds that the February 2014 opinion is inadequate to fairly adjudicate the Veteran’s claim for service connection. Although the VA examiner opined that the Veteran’s sinus condition was less likely than not caused by his service due to there being no evidence an injury was sustained in service, the examiner did not address the Veteran’s lay statements of nosebleed in service. Further, the record reveals that the Veteran sought treatment in February 1987, although the examiner stated that the Veteran did not seek treatment for 30 years following service. Additionally, in an April 2014 NOD, the Veteran stated that the stress associated with his PTSD exacerbated his sinus condition and contributed to increased nosebleeds. On remand, the examiner must opine as to whether his condition has been aggravated by his service-connected PTSD. The Board finds that the examiner did not consider the Veteran’s lay statements regarding in-service nosebleeds or the evidence indicating that the Veteran has a nasal septum perforation, rather than just a “repair of a broken nose.” The Board also notes that the evidence of record reveals that the Veteran has a “hole in nasal septum related to toxic substance exposure.” See April 30, 2016 VA treatment note. As such, the Board finds that a remand is required to obtain an addendum opinion addressing the above. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). 2. Entitlement to service connection for headaches, to include as secondary to a sinus condition is remanded. The Veteran contends that service connection for headaches, to include as secondary to a sinus condition is warranted. Finally, because a decision on the sinus condition issue could significantly impact a decision on the issue of entitlement to service connection for headaches, to include as secondary to a sinus condition, the issues are inextricably intertwined. As such, a remand is required. The matter is REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s sinus condition is at least as likely as not related to service and specifically whether the Veteran’s complaints of nosebleeds were the early manifestation of the nasal septal perforation shown in his treatment records. The examiner must also opine whether the Veteran’s sinus condition was aggravated beyond its natural progression by his service-connected PTSD. In formulating the opinion, the examiner must consider the Veteran’s lay statements. 2. Readjudicate the intertwined issue of headaches, to include as secondary to his sinus condition. 3. After the above development, and any additionally indicated development, has been completed, readjudicate the issue of entitlement to a sinus condition, including the inextricably intertwined issue of entitlement to service connection for headaches. If the benefit sought is not granted to the Veteran’s satisfaction, send the Veteran and his representative a Supplemental Statement of the Case and provide an opportunity to respond. If necessary, return the case to the Board for further appellate review. DEBORAH W. SINGLETON Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Tiffany N. Hanson, Associate Counsel