Citation Nr: 20031065 Decision Date: 05/04/20 Archive Date: 05/04/20 DOCKET NO. 17-43 057 DATE: May 4, 2020 ORDER An initial disability rating of 70 percent, but no higher, for service-connected posttraumatic stress disorder (PTSD) is granted. REMANDED Entitlement to service connection for heart disease, to include as due to exposure to herbicide agents, is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU) is remanded. FINDING OF FACT The severity, frequency, and duration of the Veteran’s symptoms of service-connected PTSD more closely approximated occupational and social impairment, with deficiencies in most areas. CONCLUSION OF LAW The criteria for an initial disability rating of 70 percent, but no higher, for service-connected PTSD are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from March 1964 to March 1967. These matters come before the Board of Veterans’ Appeals (Board) on appeal from July 2015 and March 2017 rating decisions. In the Veteran’s appeal of the March 2017 rating decision, denying service connection for heart disease, his July 2019 VA Form 9 was received more than 60 days after the May 2019 statement of the case. In March 2020, the Veteran and his wife testified at a videoconference Board hearing before the undersigned, and a transcript is of record. As the undersigned heard testimony on the issue of entitlement to service connection for heart disease, the Board takes jurisdiction of the issue pursuant to Percy v. Shinseki, 23 Vet. App. 37, 45-47 (2009). The claimant bears the burden of presenting and supporting a claim for benefits. 38 U.S.C. § 5107(a); Fagan v. Shinseki, 573 F.3d 1282, 1286–88 (Fed. Cir. 2009). In making determinations, VA is responsible for ascertaining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether the preponderance of the evidence is against the claim, in which case the claim is denied. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). Here, the Board reviewed all evidence in the claims file, with an emphasis on that which is relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380–81 (Fed. Cir. 2000) (holding that the Board must review the entire record but does not have to discuss each piece of evidence). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board’s analysis will focus specifically on what the evidence shows, or fails to show, as it relates to the Veteran’s claim. Increased Rating Disability ratings are assigned under a schedule for rating disabilities and based on a comparison of the veteran’s symptoms to the criteria in the rating schedule. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Disability evaluations are determined by assessing the extent to which a veteran’s service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the ratings schedule. Individual disabilities are assigned separate Diagnostic Codes, and ratings are based on the average impairment of earning capacity. See 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2. If there is a question as to which evaluation should be applied to the veteran’s disability, 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. The primary focus in a claim for increased rating is the present level of disability. Although the overall history of the veteran’s disability shall be considered, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Additionally, a staged rating is warranted if the evidence demonstrates distinct periods of time in which a service-connected disability exhibited diverse symptoms meeting the criteria for different ratings throughout the course of the appeal. Fenderson v. West, 12 Vet. App. 119, 125-126 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Under the General Formula for Mental Disorders (General Formula), the Board must conduct a “holistic analysis” that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). Here, the Veteran’s service-connected PTSD is rated under 38 C.F.R. § 4.130, Diagnostic Code 9411, currently evaluated as 50 percent disabling. A 50 percent rating is assigned when symptoms such 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; or difficulty in establishing and maintaining effective work and social relationships cause occupational and social impairment with reduced reliability and productivity. A 70 percent rating is assigned when symptoms such 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 worklike setting); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. A 100 percent rating is assigned when symptoms such 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; or memory loss for names of close relatives, own occupation or own name cause total occupational and social impairment. The Board notes that there is no distinction when evaluating a psychiatric disability as 70 percent disabling of whether suicidal ideation is passive or active. Bankhead v. Shulkin, 29 Vet. App. 10 (2017). An examiner’s classification of the level of psychiatric impairment at the moment of examination is to be considered, but it is not determinative of the percentage disability rating to be assigned; the percentage evaluation is to be based on all the evidence that bears on occupational and social impairment. See 38 C.F.R. § 4.126; VAOPGCPREC 10-95 (Mar. 1995); 60 Fed. Reg. 43186 (1995). Entitlement to an initial disability rating in excess of 50 percent for PTSD. The Veteran essentially contends that his PTSD symptoms are more disabling than contemplated by the initially assigned disability rating of 50 percent (the Veteran is in receipt of a 100 percent rating from October 30, 2017 to December 31, 2017). The question for the Board, therefore, is whether the Veteran’s associated symptoms of PTSD caused the level of impairment required for a disability rating of 70 percent or higher. Based upon a careful review of the probative evidence, the Board concludes that the severity, frequency, and duration of the Veteran’s PTSD symptoms more closely approximated the level of impairment associated with a disability rating of 70 percent. Reports of VA examinations for PTSD conducted in June 2015 and May 2019 show that the Veteran’s PTSD was manifested by symptoms associated with a 30 percent rating (depressed mood, anxiety, suspiciousness, chronic sleep impairment) and symptoms associated with a 50 percent rating (disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships). The Veteran also had symptoms that are not listed with a specific rating, such as flashbacks, recurrent distressing dreams, hypervigilance, and exaggerated startle response. Both examiners indicated that the Veteran’s PTSD symptoms produced occupational and social impairment with reduced reliability and productivity. Nevertheless, the May 2019 VA examiner remarked: “Vet completed a PCL5 with a score of 74. This score is well above the commonly used cutoff indicating problems with PTSD symptoms. A score this high indicates a severe level of PTSD symptoms.” During the June 2015 VA examination, the Veteran reported that his children did not come around often because of him. He stated: “I don’t do friends.” He reported that he spent his spare time sleeping; he was not interested in hobbies; and he spent time with grandchildren. It was recorded that the Veteran reported suicidal ideation in the past, without any attempts, and he denied recent suicidal ideation, plan, or intent. The examiner recorded that the Veteran was “neatly groomed, casually dressed, good rapport and eye contact,” and speech was within normal limits. In a June 2016 letter, the Veteran’s wife stated that the Veteran had always been very fearful of thunder, lightning, and fire. She stated that he was too afraid to fly or was reluctant to give up control. She stated that he had reported flashbacks, believing he was in Vietnam, once when in the woods and once while visiting the Vietnam Wall. She reported that the Veteran had trouble concentrating such that, when he was spoken to, it took him a few minutes to register it. She reported that he was withdrawn and isolated himself and that he had trouble sleeping for long periods. VA medical records show that the Veteran had an initial PTSD intake assessment in July 2016. He reported that he did not like to be social and that he did not like to have friends. The social worker noted that the Veteran sometimes described depersonalization in regard to whether dissociative features were present. Suicidal ideation was denied. Diagnoses of chronic PTSD and depression were assigned and symptoms of anxiety were noted. In subsequent sessions, anger was addressed. In October 2016, the Veteran was assessed by Dr. P.L.C., who prescribed sertraline 25 mg. It was noted that the Veteran’s speech was normal in rate, rhythm, volume, and “the Veteran [was] able to articulate sufficiently clearly for office communication.” Thought processes were logical and goal directed. The Veteran complained of difficulty managing the mood of anger. In November 2016, the Veteran was evaluated by Dr. W.M.S. Jr., during which his speech was noted as within normal limits for rate, pitch, and tone. He denied suicidal or homicidal ideation. It was noted that anxiety was rather consistent with his baseline, and, at times, it could be high. He reported having angry outbursts. Records show that the Veteran participated in bi-monthly group PTSD therapy. The Veteran was seen by Dr. P.L.C. in January 2017, and it was noted that the Veteran was “reasonably well groomed.” It was stated: “The thought processes as observed are circumstantial but not tangential and loosely associated.” Speech was “digressive,” and it was stated that in “his speech there [were] somewhat frequent remote associations.” In April 2017, the Veteran’s sertraline was increased to 50 mg. It was recorded: “The thought processes as observed are rather circumstantial and concretely associated. His speech is somewhat digressive. In his speech there are rare somewhat frequent remote associations.” In a July 2017 letter, one of the Veteran’s sons prepared an itemized list “of some of the things [the Veteran] does that are not normal:” worries all the time; calls every night to make sure his son is alright and will call until there is an answer; moody behavior; very fearful; depressed; reluctant to go out and enjoy life; negative; and lays down a lot, fatigued. In a July 2017 letter, another of the Veteran’s sons related that the Veteran was a “very fearful person.” He stated that the Veteran would call him constantly when he was out, “just because he [was] worried and anxious.” He reported that, when he was a child, one of his father’s friends explained that the Veteran did not want to be in the woods with guns with the boys while hunting because he was afraid it would trigger flashbacks or other harmful behavior. It was stated that he had had flashbacks in the woods before. It was also stated: “Also concerning violent behavior, Dad kicked me in the chest in an impulsive way of correction and hit me in the head with the remote many times.” In an August 2017 letter, the Veteran’s wife wrote in response to the statement of the case and stated that she knew the Veteran suffered from most deficiencies in most areas. She stated that the Veteran neglected his personal appearance and hygiene such that she had to remind him to take care of himself. She related that he could not handle stressful circumstances and cited a work example. Something had blown up at his place of employment, which caused a loud noise, and he went home in a panic. She stated that she had to calm him down and talked him into going back to work. She stated that she was not sure of the meaning of the criterion “spatial disorientation,” but the Veteran was “spaced out” at times, unable to focus. She related that he may take five minutes before responding to a question. She stated that he “obsessively calls his adult children late at night over and over until he reaches them before he goes to bed.” She also reported that he unplugged the microwave, toaster, and coffee pot every night. She stated that, after being around him, it was noticeable that his speech was intermittently illogical, obscure, or irrelevant. The remaining examples supporting the criteria were consistent with her hearing testimony. An October 2017 report of hospitalization shows that the Veteran was hospitalized for PTSD. VA records show that the Veteran was admitted to a domiciliary program for PTSD treatment, and an August 2018 rating decision awarded a temporary evaluation of 100 percent disabling for hospitalization over 21 days. VA medical records show that in May 2018 the Veteran was contacted by telephone over concerns of some of his responses on the NEPEC review of his PHQ 9 regarding potential suicidal ideation. He “reported having fleeting SI however no plan or intent. He reported ‘I don’t think about it as much as I used to.’” Records from a November 2018 counseling session show that the Veteran’s style of thinking could be described as personalization (veteran attributes events to oneself without a basis for the connection) and absolutist (dichotomous thinking, missing the gradations of experiences). During the May 2019 VA examination, the examiner noted that the Veteran was casually attired with acceptable grooming and hygiene. His mood was recorded as “‘not in a good mood,’” “‘just existing,’” and “‘stressed out.’” It was noted that the Veteran had a southern accent with speech “generally normal with regard to production, clarity, volume, and content.” Thought process was clear, linear, and goal-directed. Thought content was noted as normal, and no gross deficits in memory or intellectual functioning were apparent during the interview. VA medical records show that, in June 2019, records from the Home Telehealth program revealed out-of-range responses for depression in the past 30 days. When contacted, the Veteran denied being suicidal or homicidal. His financial situation was a concern and he felt that VA hindered him more than helped him in that regard. He reported that there was also an issue with custody of a grandchild. He reported that his mental health medications made him sleepy and that he did not want to get out and do anything. He reported that his mental health medications had been increased but he had not received the new prescription in the mail yet. Records show that in May 2019 the prescription for sertraline was increased to 100 mg. During the Veteran’s March 2020 hearing, his wife gave detailed testimony concerning the Veteran’s PTSD symptoms, which she contended reflect impairment associated with a disability rating of 70 percent. She used the diagnostic criteria as a guide to her presentation and gave examples of 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; and difficulty adapting to stressful circumstances. As to obsessional rituals, she stated that the Veteran’s sense of fear resulted in obsessional rituals that interfered with routine activities, such as unplugging everything. She stated that she believed he had an irrational fear of fire. She stated that, if he came home during a thunderstorm, he would sit in the car until it was over because he was afraid of lightening. She stated that their bedroom door had to be locked every night. She explained that the reason she found this irrational is that there was a small window air conditioner in the bedroom such that it would be an easier point of entry for an intruder. As for speech intermittently illogical, obscure, or irrelevant, she stated that one had to know the Veteran for a period of time to notice his conversation. She stated that it was difficult to understand and follow his train of conversation because he would start with one topic and “jump to a totally different subject and you’re still trying to understand what he’s talking about.” As to the severity of the Veteran’s panic attacks or depression, she stated that the Veteran was “a very panicky person,” which happened quite often. She stated: “It’s kind of like our life is panic.” She stated that it has been that way the whole forty-plus years they have been married. She stated that it could be over something small or something big. She stated that the Veteran’s method of coping was to get into bed and take naps. She stated that often she had to talk him into getting out of bed. She was not sure whether this was depression or difficulty adapting to stressful circumstances. As for impaired impulse control, the Veteran’s wife reported, and he endorsed her statements, that he was easily irritated and prone to irrational behavior. She used the example of when the Veteran corrected the grandchildren. Rather than talking to the child to explain a problem, the Veteran would “pop” the child on the back “and say, don’t do it.” She stated that his method of handling these situations has been a frequent dialog between them. The Veteran endorsed that he believed his judgment was impaired. As to spatial disorientation, the Veteran’s wife stated, and he agreed with her, that he has had episodes of not knowing where he was when driving. As for neglect of personal appearance and hygiene, the Veteran’s wife stated: “He doesn’t always look as nice as he looks today.” She stated that the Veteran bathed every couple of days. She stated that he had problems keeping underwear clean and had to be told to change and to clean up. She stated: “I feel like I got to keep reminding him of, you know, stuff like that.” The Veteran’s wife stated that she definitely agreed with the criterion that the Veteran had difficulty adapting to stressful circumstances. As an example, she related that, when returning something at a store, the Veteran would become very insistent as to what he expected. She stated that the week before an incident occurred at a store when the Veteran was insistent upon a particular price. The Veteran admitted to the incident. His wife stated that she had taken a picture of the price tag previously and the way she convinced the Veteran of his error was by showing him the picture. She stated that the Veteran had difficulty coping with the stressful things that came up in life. She stated he was very impatient. During the hearing, the Veteran stated that he was prescribed sertraline, which had been increased the beginning of 2019, and that his symptoms were “pretty much the same” as when he had his May 2019 VA examination. He endorsed suicidal ideations. The Veteran stated that he did not have friends because during the war he would have to deal with the death if a friend was killed. He stated that the one friend he had had died. As fact-finder, the Board has the responsibility to determine the credibility and weight to be given to the evidence. See Washington v. Nicholson, 19 Vet. App. 362, 367-68 (2005); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 300–04 (2008); Prejean v. West, 13 Vet. App. 444, 448–49 (2000) (stating that factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion). The Board notes that the Veteran and other lay witnesses are entirely competent to report the Veteran’s symptoms, and due to the consistency of the lay evidence internally as well as with the medical evidence, the Board finds the lay evidence credible and highly probative. See 38 C.F.R. § 3.159(a)(1)–(2) (defining competent medical evidence and competent lay evidence); Charles v. Principi, 16 Vet. App. 370 (2002) (finding the veteran competent to testify to symptomatology capable of lay observation); Layno v. Brown, 6 Vet. App. 465, 469–70 (1994) (noting that competent lay evidence requires facts perceived through the use of the five senses); Caluza v. Brown, 7 Vet. App. 498, 511 (1995) (explaining that lay evidence is credible when it is internally consistent and consistent with other evidence of record). Here, the lay witnesses are family members who have an intimate knowledge of the Veteran’s day-to-day functioning, which cannot be overshadowed by limited evaluations in a clinical setting. After careful review, the Board finds that the probative evidence, medical and lay, establishes that the level of impairment caused by the Veteran’s symptoms of PTSD more closely approximate the level associated with a disability rating of 70 percent. Concrete examples have been provided establishing that the Veteran exhibits obsessional rituals that interfere with routine activities; near-continuous panic or depression; impaired impulse control; difficulty in adapting to stressful circumstances; and inability to establish and maintain effective relationships. The Board accounts for his symptoms of hypervigilance and exaggerated startle response as symptoms of near-continuous panic affecting the ability to function independently, appropriately, and effectively. As to neglect of personal appearance and hygiene, the evidence shows that, when the Veteran is in public, he is presentable. The Board finds the Veteran’s wife’s testimony highly probative as to the efforts exerted to accomplish that result. As to the Veteran’s speech being intermittently illogical, obscure, or irrelevant, the Board finds that his wife’s contention that it takes time to notice this aspect is supported by the medical record. The VA examiners found the Veteran’s speech to be normal. Upon first meeting, Dr. P.L.C. noted the Veteran’s speech as being normal, but, subsequently, it was noted as digressive with circumstantial thinking. The Board notes that the Veteran has endorsed suicidal ideation, which is similar to persistent danger of self-harm, which is contemplated by the criteria for a disability rating of 100 percent. Bankhead v. Shulkin, 29 Vet. App. 10, 19 (2017). The Board finds, however, that the severity, frequency, and duration of the Veteran’s suicidal ideation has not risen to the level contemplated by the 100 percent disability rating. While the medical records show that the Veteran frequently has reported feeling sad or depressed, he regularly denied thoughts, intent, or a plan involving self-harm. He has denied any suicide attempts. Consequently, the Board finds that his suicidal ideation is contemplated by the criteria for a 70 percent disability rating. The Board notes that the Veteran has experienced flashbacks and recurrent distressing dreams, which are contemplated by the criterion of spatial orientation for a 70 percent rating and of disorientation to time or place for a 100 percent rating. Based on the evidence of record, the Veteran’s flashbacks seem to have been limited to being in woods, while handling guns when hunting, or when visiting the Vietnam Wall. As to dreams, the treatment records are silent for this symptom, but it appears in the VA examinations during detailed probing of symptomatology. The evidence concerning disorientation while driving as presented here is too general in nature to be ascribed as a PTSD symptom. Consequently, the Board finds that the expression of these unlisted symptoms more closely approximates the level associated with a disability rating of 70 percent rather than 100 percent. There is no evidence that the Veteran experiences 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; or memory loss of name of close relatives, own occupation, or own name. The Veteran has not contended otherwise. The Veteran has contended, however, in July 2017 and August 2017, that he believes that he should be found totally disabled due to his PTSD symptoms. The premise for his contention is that his PTSD symptoms were part of the reasons he became unable to work and retired. Entitlement to a separate TDIU in addition to this disability rating for his service-connected PTSD is part and parcel to an increased rating claim when it is raised by the record. Rice v. Shinseki, 22 Vet. App. 447 (2009). As the Veteran has raised the issue of entitlement to a TDIU but the record is not adequately developed for a decision on the merits, the Board is remanding the issue for further development. In conclusion, the evidence establishes that the severity, frequency, and duration of the Veteran’s PTSD symptoms more closely approximate the symptoms associated with a 70 percent disability rating: 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 adapting to stressful circumstances; and inability to establish and maintain effective relationships. The medical and lay evidence show that his symptoms produce occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, judgment, thinking, or mood, and the Board finds that a 70 percent disability rating is warranted. REASONS FOR REMAND 1. Entitlement to service connection for heart disease, to include as due to exposure to herbicide agents, is remanded. The Veteran seeks service connection for heart disease, which he contends was the result of exposure to herbicide agents while serving in Vietnam during the Vietnam War Era. The Veteran’s DD Form 214 shows that he was in receipt of the Vietnam Campaign Medal. His military personnel records show that he disembarked at DaNang, South Vietnam, in April 1965. As the Veteran had active duty service in Vietnam during the Vietnam War Era, he is presumed to have been exposed to herbicide agents. See 38 U.S.C. § 1116; 38 C.F.R. §§ 3.307(a)(6)(iii), 3.309(e). The determination of this issue bottoms on the etiology of the ischemia that caused the Veteran’s November 2016 myocardial infarction. A November 2016 hospital discharge summary listed diagnoses including acute hypoxemic-hypercapnic respiratory failure; new onset decompensated systolic heart failure with ejection fraction 35 percent; NSTEMI (non-ST segment elevation myocardial infarction); AKI (acute kidney injury); COPD (chronic obstructive pulmonary disease); and bilateral pleural effusions. It was noted that on presentation he had “some elevated troponins but thought to be from a demand-mismatch.” It was noted that NSTEMI was “suspected from demand ischemia from resp failure.” His course of care was recorded as his having prior medical history of COPD with presentation to the hospital with hypoxemia, which required intubation. While intubated, he was treated in the intensive care unit for hypoxic and hypercapnic respiratory failure. It was stated that he had “acute hypoxemic-hypercapnic respiratory failure from chronic obstructive pulmonary disease exacerbation and bronchitis and plural effusions.” Medical records show that in November 2016 the Veteran was evaluated due to acute hypoxic hypercapnic respiratory failure with COPD. A November 2016 EKG revealed T wave abnormalities suggestive to consider inferior and anterolateral ischemia. An echocardiogram revealed depressed systolic function with global hypokinesis and restrictive diastolic pressures and an ejection fraction of 35 percent. Left-sided chambers were enlarged and mild pulmonary hypertension was seen. VA medical records show that, in November 2016 after the Veteran’s hospitalization, Dr. R.E.T. diagnosed COPD and cor pulmonale. In December 2016, Dr. B.S.H. diagnosed hypertensive heart disease with heart failure, stable on carvedilol, lisinopril, and hydralazine therapy; and chronic combined systolic and diastolic heart failure, stable on lisinopril and carvedilol therapy. A January 2017 report of myocardial perfusion imaging report stated: “LV myocardial perfusion was consistent with 0 vessel disease.” It was noted that myocardial perfusion was normal. VA medical records show that a January 2017 echocardiogram revealed an ejection fraction of 49 percent, and “stress test negative for ischemia.” In February 2017, the Veteran was afforded a VA examination for heart conditions, during which November 2016 diagnoses of congestive heart failure and hypertensive heart disease were noted. The examiner recorded: “Denies MI.” The examiner indicated that the Veteran’s heart conditions did not qualify within the generally accepted medical definition of ischemic heart disease. For heart condition #1, the provided etiology was “CHF/hypertension,” and for heart condition #2, the provided etiology was “Hypertensive heart disease/hypertension, heart failure.” The Veteran’s cardiac medications were noted, and it was indicated that the Veteran had not had a myocardial infarction. The examiner explained that the Veteran’s two heart conditions were associated with uncontrolled long duration of hypertension, “which per Nehmer’s training guidelines, are not deemed IHD.” It was noted that the Veteran did not have a history of coronary artery disease, which would be consistent with ischemic heart disease. VA medical records show that Dr. R.E.T. entered into the Veteran’s problem list a diagnosis of coronary atherosclerosis in May 2017. Records show that in July 2018 the Veteran was seen by a new primary care physician, Dr. S.D., who recorded that the Veteran was presenting “for follow up on HTN, CAD, IFG.” Coronary artery disease was added to the Veteran’s active problem list. The Board observes that the February 2017 VA examiner appears not to have reviewed the Veteran’s claims file with any attention for detail or to have listened to the Veteran’s report of medical history. It was noted that the Veteran denied having had a myocardial infarction, which is not accurate as to the lay evidence of record and is unlikely during the examination considering his contention. The examiner’s conclusion that the Veteran had not had a myocardial infarction is inconsistent with the November 2016 medical records. While the examiner indicated that the Veteran’s heart condition did not qualify within the generally accepted medical definition of ischemic heart disease, the explanation provided for etiology was circular and uninformative. Consequently, the Board finds the February 2017 VA examination inadequate. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that a medical opinion based upon an inaccurate or incomplete factual premise is not probative). On remand, a new VA examination is required to determine the nature and etiology of the Veteran’s heart disease, taking into account his past medical history, the record evidence, and accepted medical principles. 38 C.F.R. § 3.159(c)(4). 2. Entitlement to a TDIU is remanded. When raised by the record, a TDIU claim is part and parcel of an increased rating claim such as the one at issue here. Rice v. Shinseki, 22 Vet. App. 447 (2009). In a July 2017 letter, the Veteran stated that he was no longer able to work after having been put on short-term disability than long-term. He stated: “I could no longer perform my job duties.” In an August 2017 letter, the Veteran stated that symptoms of PTSD existed his entire life since serving in Vietnam. He stated that he retired due to other medical conditions “and also know that PTSD was part of [his] medical condition and did retire due to this condition also.” The Board notes that the Veteran is service-connected for: PTSD; tinnitus; type II diabetes mellitus to include diabetic neuropathy; and bilateral hearing loss. In November 2017, VA acknowledged the Veteran’s letters as an informal claim for TDIU. Further development is necessary. Also, the claim is inextricably intertwined with the claim remanded herein. These matters are REMANDED for the following actions: 1. Issue a notice letter to the Veteran concerning the claim for a TDIU. Ask him to complete VA Form 21-8940, Veteran’s Application for Increased Compensation Based on Unemployability. Upon receipt of the form, complete any necessary additional development. 2. Schedule the Veteran for an appropriate examination to determine the nature and etiology of his heart disease. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including this Remand, and to indicate review of the file in the examination report. The examiner is advised that the Veteran is presumed to have been exposed to herbicide agents during service in Vietnam. Particular attention should be given to: (1) the November 2016 hospital discharge summary and medical records showing that the Veteran’s pre-existing COPD was exacerbated by an episode of bronchitis with plural effusions, which resulted in hypoxemia. Due to the severity of the Veteran’s reduced blood oxygenation and elevated carbon dioxide, he was intubated to treat acute hypoxemia and hypercapnic respiratory failure during which he suffered a non-ST segment elevation myocardial infarction and congestive heart failure; (2) January 2017 myocardial perfusion imaging report showing no coronary vessel disease; (3) January 2017 echocardiogram report stating that stress test was negative for ischemia; (4) entries into the Veteran’s problem list of coronary atherosclerosis in May 2017 and of coronary artery disease in July 2018. The examiner must obtain a full history from the Veteran. It should be noted that the Veteran is competent to attest to factual matters of which he has first-hand knowledge, such as observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. Please provide responses to the following: (a) Does the Veteran have a type heart disease that qualifies within the generally accepted medical definition of ischemic heart disease? (b) Please explain the distinction, if any, in development of ischemic heart disease and the Veteran’s clinical presentation of heart disease. (c) Please state whether there is any clinical evidence of record to support the 2017 and 2018 entries into the Veteran’s problem list of diagnoses of coronary atherosclerosis and coronary artery disease. (d) Please indicate whether the Veteran’s heart disease is at least as likely as not (50 percent or greater probability) due to or aggravated by an in-service injury, event, or disease, to include as due to exposure to herbicide agents. The examiner must reconcile any opinion with the evidence of record, citing to the record as appropriate. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. The examiner must address any conflicting medical evidence of record. If the examiner is unable to offer the requested opinion, it is essential that the examiner offer a rationale for the conclusion that an opinion could not be provided without resort to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 3. Readjudicate the claims on appeal. L. CHU Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Leanne M. Innet, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.