Citation Nr: 21070556 Decision Date: 11/24/21 Archive Date: 11/24/21 DOCKET NO. 14-29 115A DATE: November 24, 2021 ORDER Entitlement to service connection for cerebrovascular accident (CVA), to include as due to exposure to an herbicide agent, is denied. Entitlement to service connection for chronic gastric vomiting, to include as due to exposure to an herbicide agent, is denied. Entitlement to service connection for gastric hyperplasia, to include as due to exposure to an herbicide agent, is denied. Entitlement to service connection for soft-tissue inflammation, to include as due to exposure to an herbicide agent, is denied. Entitlement to total disability evaluation based on individual unemployability, due to service-connected disabilities (TDIU), prior to July 18, 2014, is denied. FINDINGS OF FACT 1. The objective medical evidence does not show CVA was incurred during active service, it is not caused by an event, injury or illness occurring in active service, it did not manifest to a compensable degree within 1 year of separation from active service, it is not a result of exposure to an herbicide agent, and no presumption of service connection based on such exposure is otherwise applicable. 2. The objective medical evidence does not show chronic gastric vomiting was incurred during active service, it is not caused by an event, injury or illness occurring in active service, it is not a result of exposure to an herbicide agent, and no presumption of service connection based on such exposure is otherwise applicable. 3. The objective medical evidence does not show gastric hyperplasia was incurred during active service, it is not caused by an event, injury or illness occurring in active service, it is not a result of exposure to an herbicide agent, and no presumption of service connection based on such exposure is otherwise applicable. 4. The objective medical evidence does not show soft-tissue inflammation was incurred during active service, it is not caused by an event, injury or illness occurring in active service, it is not a result of exposure to an herbicide agent, and no presumption of service connection based on such exposure is otherwise applicable. 5. The evidence of record shows prior to July 18, 2014 the Veteran's service-connected disorders alone did not cause him or the average person to be unable to secure or follow a substantially gainful occupation, nor does the record present an exceptional disability picture to warrant referral to the Director of the Compensation Services for extraschedular consideration. CONCLUSIONS OF LAW 1. The criteria for service connection for CVA, to include as a result of exposure to an herbicide agent, have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1116, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2020). 2. The criteria for service connection for chronic gastric vomiting, to include as a result of exposure to an herbicide agent, have not been met. 38 U.S.C. §§ 1110, 1116, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2020). 3. The criteria for service connection for gastric hyperplasia, to include as a result of exposure to an herbicide agent, have not been met. 38 U.S.C. §§ 1110, 1116, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2020). 4. The criteria for service connection for soft-tissue inflammation, to include as a result of exposure to an herbicide agent, have not been met. 38 U.S.C. §§ 1110, 1116, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2020). 5. The criteria for TDIU prior to July 18, 2014, have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.16, 4.25 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Navy from November 1967 to December 1970, during part of which he was deployed to the Republic of Vietnam and for which service, in addition to his other medals and decorations, he was awarded the Vietnam Service Medal, with Fleet Marine Combat Insignia, with 1 Bronze Star. Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from a disease or injury incurred in active service or that a preexisting injury or disease was aggravated by active service. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303 (a) (2017). Establishing service connection generally requires: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred in or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Certain chronic diseases may be service connected on a presumptive basis if manifested to a compensable degree in a specified period after service. 38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. That period is usually one year. 38 C.F.R. § 3.307 (a)(3). For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. 38 C.F.R. § 3.303 (b). Under 38 C.F.R. § 3.303 (b), an alternative method of establishing and in-service disease or injury and a nexus for chronic diseases is through a demonstration of continuity of symptomatology. Barr v. Nicholson, 21 Vet. App. 303 (2007); see Savage v. Gober, 10 Vet. App. 488, 495-97 (1997); see also Clyburn v. West, 12 Vet. App. 296, 302 (1999). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Savage, 10 Vet. App. at 495-96; see 38 C.F.R. § 3.303 (b). Exposure to an Herbicide Agent A veteran who, during active military, naval or air service, served in the Republic of Vietnam during the Vietnam era shall be presumed to have been exposed during his or her service to an herbicide agent, unless there is affirmative evidence to the contrary. 38 U.S.C.§ 1116 (f); 38 C.F.R. § 3.307 (a)(6)(iii). The following diseases will be deemed service connected if the requirements of 38 C.F.R. § 3.307 (a) are met, even if there is no record of such disease during service: AL amyloidosis, chloracne or other acneform disease consistent with chloracne; type 2 diabetes (also known as Type II diabetes mellitus); Hodgkin's disease; chronic lymphocytic leukemia (CLL); multiple myeloma; Non-Hodgkin's lymphoma; early-onset peripheral neuropathy; porphyria cutanea tarda; prostate cancer; respiratory cancers (cancer of the lung, bronchus, larynx or trachea); soft tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma), chronic B-cell leukemias, Parkinson's disease, and ischemic heart disease. 38 C.F.R. § 3.309 (e). To benefit from the presumption of service connection for diseases associated with herbicide-agent exposure, the Veteran must have one of the diseases set forth in 38 C.F.R. § 3.309 (e). However, when diseases do not appear under the regulation, a veteran can still proceed to establish service connection on a direct basis. See Combee v. Brown, 34 F.3d 1039, 1045 (Fed. Cir. 1994). At the outset, the Board will briefly note here that VA has conceded the Veteran's exposure to an herbicide agent. 1. Entitlement to service connection for CVA, to include as due to exposure to an herbicide agent. The service treatment records (STRs) show in August 1970, the Veteran received a hit on his head with an unknown object. He presented with a stellate (star shaped) laceration approximately 2 inches long on the right posterior of his scalp. He bled "quite profusely" on his way to x-rays and suturing. The Veteran reported he did not lose consciousness and the treatment provider found on examination the Veteran's pupils were "equal." The wound was cleaned, sutured and dressed. Approximately a week later the sutures were removed with very little drainage, showing the wound had healed well. The September 1967 enlistment examination and the November 1970 separation examination show the examiner found the Veteran's head and scalp to be normal. Additionally, the Veteran reported in the enlistment examination he had no past or current history of a head injury, frequent or severe headache or dizziness or fainting spells. The STRs show no reports, complaints, treatment, or diagnoses of a stroke or any cerebrovascular-related disorder. The post-active-service record shows in September 1996, the Veteran underwent a private treatment CT head scan, the findings of which revealed a thalamic hematoma, indicated either a hemorrhagic cerebrovascular accident or a hemorrhagic neoplasm. Private treatment records show the Veteran's May 1997 assessment included "CVA - hemorrhagic." An August 2011 VA primary care physician note identifies the Veteran's history of hemorrhagic CVA, stating its date as 1998. The treatment provider's impression included, "Late effects of cerebrovascular accident: Mild short-term memory loss, dysequilibrium, and slight numbness of the entire left side of his body. Control risk factors." The Veteran's VA primary care physician in December 2015 noted the Veteran's history of a stroke as a hemorrhagic CVA (1998), involving the inferior thalamic artery. He noted the Veteran's reports of being left with some short-term memory loss, dysequilibrium and slight numbness of the entire left side of his body. The treatment provider noted a June 2014 MRI of the brain with contrast revealed no abnormal intracranial enhancement; no intracranial mass lesions; small focus of T2 FLAIR [sic] hyperintensity within the left midbrain, which likely represented an old area of ischemia and an old infarct within the right subinsular white matter/external capsule with associated old blood products. In February 2021, the Veteran reported on a VA telephone advice note that he had presented to a VA emergency department several days earlier for a possible stroke, after symptoms of light-headedness and dizziness. In its December 2018 Remand, the Board noted CVA is not among the diseases eligible for presumptive service connection based on exposure to an herbicide agent is available under 38 C.F.R. § 3.309 (a). However, the Veteran is not precluded from establishing service connection for disability due to herbicide exposure with proof of direct causation. See Combee v. Brown, 34 F.3d 1039, 1042, 1043-44 (Fed. Cir. 1994). For that reason, the Board directed an VA examination be conducted. As this directive was not fulfilled, the Board's February 2021 Remand again requested the examination, stating the Veteran's exposure to an herbicide agent, to include Agent Orange, is presumed in light of the specific circumstances of his service and even though service connection may not be presumed given the current evidence of record, a determination should be made as to whether the Veteran's presumed exposure directly caused conditions involving CVA. The Veteran was afforded an April 2021 VA examination for central nervous system and neuromuscular diseases (associated with the file in May 2021), in which the examiner stated 1998 and 2014 diagnoses of thrombosis, transient ischemic attack or cerebral infarction and a hemorrhagic stroke. He noted the Veteran's reports of suffering a hemorrhagic stroke leading to hospital admission, experiencing left hemiparesis which mostly gradually resolved and being informed in 2014 of evidence of a small ischemic stroke after imaging was performed. He further reported he has not used tobacco since the 1980s and he drank alcohol regularly prior to reducing intake around 2 years ago and now has reduced intake to 1 or 2 beers daily most days. This report is consistent with his submitted June 2021 statement. After testing and examination, the examiner offered a series of opinions in response to the Board's several questions. To the question of whether the Veteran has a current diagnosis related to CVA, and if so, whether it is at least as likely as not (a 50 percent or greater probability) that any such diagnosis (a) had an onset in service or (b) is otherwise related to service, to include consideration of the head injury noted in the August 11, 1970, service treatment records, the examiner first opined it is less likely than not that the Veteran's CVA was otherwise related to service. He explained in his rationale that the Veteran has a current diagnosis of hemorrhagic stroke (CVA in 1998) and an ischemic stroke or CVA noted in 2014. However, there is no evidence suggestive of an onset of stroke or CVA during service in the records provided. He further explained that the Veteran's in-service head concussion would less likely than not have contributed to a CVA roughly 30 years later as there is no evidence available to establish an etiologic link between these 2 events. Medical records note a history of heavy drinking, a well-established risk factor for hemorrhagic stroke. In an alcohol screening... from July 16, 2018, the veteran states he drank at least 3-4 beers daily and on a monthly basis consumed 6 or more beers per occasion. There is also a report of DUI [criminal charge of driving under the influence of alcohol]. This drinking pattern is consistent with a diagnosis of alcohol abuse. Per the veteran's report this alcohol abuse occurred during the time of diagnosis of the veteran's two strokes. Medical records also indicate a 10 to 20-pack-year smoking history, another well-established risk factor for CVA. Additionally, medical records (see note from 8/16/2020) note that the veteran suffered sleep disturbances that resolved with the cessation of alcohol abuse. Sleep disturbances and sleep apnea, which the veterans suffers from and which is [sic] worsened by alcohol use, are risk factors for hypertension, which also increases the likelihood of CVA. Therefore it is more likely than not that the veteran's non-service related risk factors led to development of his CVAs. The examiner further opined that it is less likely than not that there is a service-related cause of the Veteran's CVAs, including presumed herbicide agent exposure that would have occurred roughly 30 years prior to the development of the veteran's first CVA. He explained that, as noted above, the Veteran has several well-established risk factors and histories of alcohol and tobacco abuse outside his military service for the development of stroke. The veteran's alcohol abuse occurred during the time of diagnosis of his CVAs. Thus (sic) it is less likely than not that there is a service-related cause of his CVAs, including presumed herbicide agent exposure that would have occurred roughly 30 years prior to the development of the veteran's first CVA. The Board has carefully considered the Veteran's statement accompanying his September 2013 Notice of Disagreement and his June 2021 correspondence statement, as well as the Veteran's reports to treatment providers and examiners as they appear throughout the record. Lay evidence may be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition (i.e., when the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer); (2) the layperson is reporting a contemporaneous medical diagnosis, or; (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F. 3d 1372, 1377, n. 4 (Fed. Cir. 2007). However, laypersons have generally been found to not be competent to provide evidence in more complex medical situations. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (concerning rheumatic fever). Here, the Veteran has some medical training (see TDIU section below, describing work history further). He is also competent to state what he has observed regarding the CVA disability. The Board will consider and weigh that along with the rest of the evidence. The Board must then determine if the evidence is credible; in determining whether documents submitted by a veteran are credible, the Board may consider internal consistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 506 (1995). The third step of this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. The Veteran contends his statements and reports regarding CVA that it, in conjunction with other related cardiovascular diseases, had their origins in active service. Moreover, he specifically contends he does not have an alcohol or drug dependency issue, he does not mix medications and alcohol, he never drinks 6 beers, to which the April 2021 VA examiner refers, but has one only occasionally, and the DUI charge, also noted by the April 2021 examiner, occurred more than 50 years ago. Additionally, he points out the examiner did not note the Veteran had lost 60 pounds, due to changes to his diet, including no alcohol for 18months and, although he smoked in his 20s, he quit over 40 years ago. The Board will first note that, although the Veteran states he was completely abstinent from alcohol abuse for 18 months, the record under consideration for his service connection claims is from separation from active service in December 1970 to the present. As such, the Board's review of the record shows in a January 2014 VA nursing note, the Veteran reported having 2 to 3 beers a day and in an alcohol screening, the Veteran reported having a drink containing alcohol 4 or more times per week, having 3 to 4 such drinks per day in the past year, but never drinking 6 or more such drinks on 1 occasion in the past year. An August 2014 private treatment notes at the A.S.C. shows the Veteran reported his alcohol usage as "[o]ccasional[,] social." An October 2015 VA nursing note shows, in an alcohol screening, the Veteran reported having a drink containing alcohol 4 times monthly or less, having no such drinks per day in the past year and, once again, never drinking 6 or more such drinks on 1 occasion in the past year. However, in a December 2016 VA nursing note, the Veteran reported in an alcohol screening having a drink containing alcohol 4 or more times per week, having 1 to 2 such drinks per day in the past year and drinking 6 or more such drinks on 1 occasion less than monthly in the past year. Although in June 2017, the Veteran reported during a VA psychiatric consult evaluation that he had no problematic use of alcohol, a July 2018 VA primary care physician note shows an alcohol screening in which the Veteran reported drinking alcohol 4 or more times per week, having 5 to 6 drinks per day in the prior year and 6 or more drinks on 1 occasion weekly in the past year. The treatment provider noted this was above recommended alcohol limits. An April 2019 VA primary care outpatient note shows in the Veteran's alcohol screening that he reported having a drink containing alcohol 4 or more times per week, having 1 to 2 such drinks per day in the past year and drinking 6 or more such drinks on 1 occasion less than monthly in the past year. However, the Veteran further reported he had stopped all alcohol in the past 7 months. Although the Veteran's August 2020 VA note shows he reported abstinence from alcohol "since 2019," a September 2020 VA administrative notes shows the Veteran reported of 2 to 3 beers, 3 days a week. A December 2020 primary care note shows in the Veteran's alcohol screening that he reported having a drink containing alcohol 4 or more times per week, having 1 to 2 such drinks per day. In a March 2021 VA mental health note, he reported "a beer once in a while." The foregoing examples from the record simply show at various times the Veteran drank varying amounts of alcohol. The April 2021 examiner noted this and concluded from the record there nonetheless is a pattern of alcohol use which he further concluded would have deleterious effects on the Veteran's vascular system. Moreover, he noted a 10 to 20-pack-year smoking history, "another well-established risk factor for CVA," irrespective of when the Veteran quit. In consideration of all the above facts documented in the file, the Board assigns more probative weight to the findings of the April 2021 VA examiner for central nervous system and neuromuscular diseases. The examiner is a current medical practitioner. The opinion shows the file was thoroughly reviewed. The Veteran's medical history was considered. The examiner interviewed the Veteran and provided sound rationale. For the reasons now stated at length, his findings and opinions therefore are adequate for VA adjudication purposes. See generally Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (noting that the central issue in assessing the adequacy of an opinion is whether the examiner was informed of the relevant facts in rendering a medical opinion). The record shows a history of a 1998 hemorrhagic stroke, the effects of which were described in an August 2011 VA primary care physician note as "[m]ild short-term memory loss, dysequilibrium, and slight numbness of the entire left side of [the Veteran's] body." However, regardless of the effects of the stroke on the Veteran at that time and afterward, nothing in the record establishes a nexus between any in-service event, injury or illness, to include concussed head and scalp laceration, and this post-active-service cerebro-vascular accident. Additionally, among the April 2021 examiner's diagnoses is thrombosis, which may be eligible for presumptive service connection as a "chronic disease." 38 C.F.R. § 3.309 (a). However, as already stated, the STRs show no treatment or diagnoses for any form of stroke or stroke-related disorder. Moreover, the STRs show the Veteran's head injury during active service exhibited signs and symptoms of nothing more than a conventional contusion and lacerated scalp. There is nothing else in the STRs to suggest otherwise. Additionally, looking to the possibility of continuity of symptomatology establishing a nexus between any in-service event, injury or illness and stroke as a subsequent chronic disease, and putting aside the lack of relevant medical evidence of any treatment prior to that time, it is otherwise impossible to establish continuity of symptomatology by relating the Veteran's current stroke residuals to an event, injury or illness in active service on any evidentiary basis. Consequently, the presumption of service connection for CVA, as a chronic disease, is not available to the Veteran. For the foregoing reasons and based on the evidence of record, to include lay evidence, the Board finds the preponderance of the evidence is against the claim for service connection for CVA, direct or presumptive. 2. Entitlement to service connection for chronic gastric vomiting, to include as due to exposure to an herbicide agent. 3. Entitlement to service connection for gastric hyperplasia, to include as due to exposure to an herbicide agent. The September 1967 enlistment examination and the November 1970 separation examination show the examiner found the Veteran's abdomen and viscera to be normal. Additionally, the Veteran reported in the enlistment examination he had no past or current frequent indigestion or stomach, liver or intestinal trouble. The STRs show no reports, complaints, treatment, or diagnoses of chronic vomiting, an enlargement of organic cell tissue, gastritis, gastroesophageal reflux disease (GERD), or any related gastrointestinal disorder. The post-active-service record shows in August 2005, the Veteran presented to the emergency room of TCH with isolated vomiting and some left upper quadrant abdominal pain, reporting it has been chronic for a year. Results of a CT head scan, an ear, nose and throat (ENT) evaluation and an electrocardiogram (EKG) eliminated possible related disorders of the central nervous system or a vestibular disorder which might cause recurrent vomiting, as well as there being no evidence of pancreatitis of hepatitis. X-rays revealed a normal upper gastrointestinal tract. Moreover, it appeared from the Veteran's reports there never had been a diagnosis for his disorder. An August 2005 esophagogastroduodenoscopy (EGD) detected mild peptic esophagitis, itself probably "a secondary phenomena [sic] to all the vomiting," but findings otherwise were unremarkable, as the stomach distended and collapsed normally. In September 2006, the Veteran reported nausea, vomiting and abdominal pain. Testing for gastric emptying revealed time for emptying was slightly prolonged, indicating mild gastroparesis. The Veteran returned in August 2008 with the same recurrent nausea and vomiting. The treatment provider noted no typical signs and symptoms of esophagitis. The Veteran reported no smoking and only social drinking of alcohol, not to excess. In an August 2008 note, Dr. J.S. observed that "[m]y plan is to treat him aggressively with acid suppression and do a followup endoscopy in 4 weeks. If this is healed, then I think we are finished. If it is not, then we will get some biopsies to try and see if we can understand why this abnormality persists." The October 2008 endoscopy showed persistent irritation along the crests of the gastric folds in an isolated area of the anterior gastric body. A September 2008 endoscopy conducted by Dr. J.S. revealed diffuse erythema of the gastric lining with an area of more pronounced irritation, but the treatment provider could not determine whether this was due to medication or to traumatic irritation from forceful emesis. In his impression in September 2008, Dr. J.S. observed, "The etiology of this remains elusive. Gallbladder disease is considered, but with resolution with Bentyl I am more suspicious of something in the realm of a motility disorder, possibly an unusual manifestation of irritable bowel syndrome." October through December 2008 private treatment records show the Veteran was treated for a 4-year history of nausea, persistent vomiting and occasional abdominal cramping, with earlier repeated evaluations by a physician since 1996, with hospitalizations (most recently a year prior) and with gastroscopies showing only gastric erythema which "may very well have been vomiting." The December 2008 impression was "[l]ong history of occasionally intractable nausea and vomiting, minimally decreased ejection fraction on hepatobiliary imaging study." A September 2011 VA primary care physician note shows the Veteran's reports of vomiting bile about once per month after becoming nauseated in morning. An October 2011 note states a gastroscopy revealed gastric erythema, but nonetheless showed improvement from the September 2008 gastroscopy. The treatment provider also noted that "we think the vomiting (since at least 1996) is related" to an anxiety condition the Veteran developed since his stroke, the treatment provider further noting the Veteran's report of "not being able to handle more than one thing coming at me at a time." In December 2015, the Veteran's VA primary care physician noted the Veteran's history of vomiting as a chronic problem (for years) with bouts of nausea and vomiting, lasting 1-5 days, about once per week. Generally, there was no odynophagia, dysphagia, abdominal pain, hematemesis, or melena, but he does have alternating constipation and loose bowel movements. "His gastroenterologist believes that pt [patient] may have gastroparesis (delayed gastric emptying, possibly causing nausea and vomiting), possibly related to pt's exposure to Agent Orange during his service in Vietnam," further noting the Veteran had not yet undergone an esophagogastroduodenoscopy (EGD). The Veteran's February 2016 EGD for GERD revealed gastroesophageal junction, z-line, and squamocolumnar junction visualized showing mild gastritis antrum and pylorus and duodenitis of the duodenal bulb. Biopsy were taken. In June 2018, the Veteran's VA primary care physician noted the Veteran's report of gastroparesis not being "much of a problem in the past several months," as nausea, vomiting, and regurgitation are "infrequent." Between August and December 2020, the Veteran reported to his VA treatment providers nausea and vomiting about once a week, sometimes lasting 1 to 5 days, with some gaps of 2 to 3 weeks. By February 2021, he reported no new onset of vomiting. For the same reasons stated in the previous section, presumptive service connection based on exposure to an herbicide agent is not available for chronic gastric vomiting and gastric hyperplasia, but establishing service connection on a direct basis remains a possibility. The Board's February 2021 Remand directed VA examinations be conducted for that purpose. In the April 2021 VA examination for stomach and duodenal conditions, the examiner at the outset found the Veteran's does not have any past or current stomach or duodenum disorders. He noted the Veteran's reports of frequent episodes of gastritis and reflux during military service continued after release from duty, the Veteran received several gastrointestinal studies in the early 2000s, he received a diagnosis of gastric inflammation secondary to reflux 5 years ago, gastrointestinal symptoms improved markedly after intentional weight loss and alcohol reduction approximately 2 years prior, and the course of the disorder has improved since onset. He further reported occasional symptoms of regurgitation associated with a daily feeling of nausea in the mornings. The examiner found no signs or symptoms associated with stomach and duodenal disorders, no incapacitating episodes and no associated conditions. He remarked at the end of the examination report, "There is no objective evidence to support a diagnosis at this time. Veteran has subjective symptoms of nausea that is transient, 4 or more episodes per year with average duration of less than 1 day." In a second examination for esophageal conditions, the April 2021 VA examiner diagnosed GERD. He noted the Veteran's reports of frequent episodes of gastritis and reflux during military service, continuing after release from duty, he was diagnosed with gastroparesis by an outside physician with a motility study in roughly 2000, 5 years ago he was diagnosed with gastric inflammation secondary to reflux, losing 50 pounds over the last 2 years due to weight loss and reduction of alcohol intake significantly helped his gastric symptoms, including resolution of his regurgitation, avoidance of trigger foods also improves his regurgitation, and after reducing alcohol intake he no longer required PPI (proton pump inhibitor drugs, for reduction of gastric acid secretion in the treatment for ulcers and GERD). The Veteran further reported frequent nausea in the mornings, resolving with activity and time, occasionally leading to regurgitation of non-bloody stomach contents and, although undergoing a cholecystectomy in 2015, it resulted in no relief of his condition. The examiner opined that as the Veteran's gastrointestinal symptoms appear linked to his history of alcohol abuse, it was less likely than not that his gastric-reflux is secondary to his military service. He explained in his rationale the Veteran has a current diagnosis of gastric reflux, his history of chronic vomiting appears to have improved significantly with the reduction in alcohol intake, suggesting alcohol abuse as the likely etiology of this condition, and alcohol abuse is a well-established cause of gastritis and vomiting. "In support of this etiology, it is noted in an 8/16/2020 medical record that the veteran was able to discontinue a PPI, a medication taken for esophageal symptoms, after reducing alcohol intake. The veteran now reports occasional regurgitation and nausea more characteristic of gastric reflux. As the veteran's GI [gastrointestinal] symptoms appear linked to his history alcohol abuse, it less likely than not that his gastric-reflux is secondary to his military service." Looking again to the Veteran's June 2021 correspondence statement, the Veteran contends the gastroenterologist's opinions agree that his nausea, vomiting, and reflux/gastritis is the result of partial paralysis (due to chemical toxicity) of gastric peristalsis (gastroparesis) leading to backup and reflux of caustic gastric juices causing nausea, vomiting and mucosal irritation, even with improvement with weight loss and the use of an adjustable bed. However, as just stated above, the April 2021 VA examiner noted in the medical evidence of record that, as alcohol intake lessened, improvements in chronic vomiting followed, shown by the Veteran being able tolerate the discontinuance of PPI drugs. In his March 2019 correspondence statement, the Veteran contends Dr. J.A.C. and Dr. J.S. stated his gastrointestinal disorder is most likely the result of exposure to Agent Orange, causing impaired motility, by which stomach contents are removed from the stomach, to the small intestine causing recurring nausea and vomiting as gastric contents including bile fill his stomach. Dr. J.A.C.'s February 2014 medical statement only states "[p]atient claims that he has been exposed to chemic[al] agent (agent orange)." She does not state his gastrointestinal disorder is most likely the result of exposure to Agent Orange, but rather recommends that the Veteran be evaluated for "possible gastrointestinal disorder probably related to exposure to external chemical agents (agent orange) (emphasis in original)." Her recommendation is based entirely on the Veteran's report and she comes to no conclusion beforehand. The Veteran's VA primary care physician in December 2015 noted that the Veteran's gastroenterologist "believes that the Veteran may have gastroparesis (delayed gastric emptying, possibly causing nausea and vomiting), possibly related to his exposure to Agent Orange during his service in Vietnam." The Veteran's gastroenterologist was Dr. J.S., who performed an August 2005 endoscopy which, other than peptic esophagitis, showed normal findings, to include the stomach distended and collapsed normally. An August 2008 note shows Dr. J.S. planned aggressive treatment with acid suppression and a followup endoscopy, after which, if not successful, he further planned taking biopsies "to try and see if we can understand why this abnormality persists." In regard to the September 2008 endoscopy, Dr. J.S.'s impression was, "The etiology of this remains elusive. Gallbladder disease is considered, but with resolution with Bentyl I am more suspicious of something in the realm of a motility disorder, possibly an unusual manifestation of irritable bowel syndrome." The Veteran's February 2016 (Dr. E.) record for esophagogastroduodenoscopy (EGD) for GERD revealed gastroesophageal junction, z-line, and squamocolumnar junction visualized showing mild gastritis antrum and pylorus. Biopsy taken. Duodenitis duodenal bulb." A VA primary care physician note in December 2016 takes note of the February procedure, stating the Veteran "[h]ad been having nausea and vomiting for years d/t [due to] small intestines not moving regularly, apparently [due to] Agent Orange (emphasis added)." This note, too, indicates exposure to an herbicide agent as a cause is based on the Veteran's report, not on any endoscopic findings or laboratory analysis. The above notes by Dr. J.S., as well as those of the February 2016 EGD, do not produce findings confirming a relationship to exposure to an herbicide agent. The above notes show no conclusion offered by Dr. J.A.C., Dr. J.S., the EGD physician, or the Veteran's VA primary care physician that GERD or any other gastrointestinal disorder "is most likely" the result of exposure to an herbicide agent, as the Veteran has asserted in the March 2019 correspondence statement. No findings were produced from which such a conclusion was ever made over the course of approximately 16 years. The summary of the record of treatment and examination during active service shows no complaints, treatment or diagnoses pertaining to any gastric disorder. The post-active-service record summary sets forth the history of endoscopies and other testing of the Veteran's gastric disorders, to include nausea, emesis (vomiting), abdominal pain, GERD, and by extension, any presentation which might relate to enlargement of an organ or tissue caused by an increased number of tissue cells, thereby indicating gastric hyperplasia. The Veteran has given his account of statements by several treatment providers, who he claims gave opinions on causation by exposure to an herbicide agent. The Veteran is competent to report what he heard and the Board does not doubt his credibility of what he believes he was told. However, in looking to the record of medical statements and treatment notes to which the Veteran has referred, the reading of those statements and notes does not credibly support the Veteran's interpretation. As discussed above at length, exposure to an herbicide agent was noted by various treatment providers, based on the Veteran's reports. However, no treatment provider ever made findings on examination or in laboratory analyses establishing a causal relationship of any gastric-related disorder to and event, injury, illness, or disease, to include exposure to an herbicide agent, occurring in active service. For the foregoing reasons and based on the evidence of record, to include lay evidence, the Board finds the preponderance of the evidence is against the claims for service connection for chronic gastric vomiting and gastric hyperplasia on any basis. 4. Entitlement to service connection for soft-tissue inflammation, to include as due to exposure to an herbicide agent. The September 1967 enlistment examination and the November 1970 separation examination show the examiner found the Veteran's skin and lymphatics to be normal, although in the separation examination he noted some "body marks and scars," with no further information provided. Additionally, the Veteran reported in the enlistment examination he had no past or current skin diseases. The post-active-service record shows private treatment records which make any reference to "soft tissue" include a January 2000 chest x-ray finding unremarkable soft issues and bones overall, an August 2005 CT scan of the abdomen and pelvis, revealing an irregular hypodense-oval soft-tissue mass on the lower pole of the right kidney, and August 2007 chest x-rays showing lungs, midline structures, bones, and soft tissues "appear[ing] unchanged." Between July 2011 and August 2020 in visits to VA, other than acne comedones, the Veteran denied any tissue lesions at all, from his genitals to his eyes and further denied lumps in his neck until December 2015, when a VA treatment provider excised a cyst from the Veteran's posterior neck. A VA nursing outpatient note in January 2014 notes the Veteran underwent surgery for a left-thumb Schwannoma (benign skin tumor) in 1992. In the April 2021 scars examination (associated with the file in May 2021), the examiner diagnosed left-wrist surgical scar. He noted the Veteran's reports of having a surgical repair of the left-wrist flexor-tendon rupture in 1972 and undergoing a 1990 left-wrist carpal tunnel syndrome release. The examiner made further findings on examination. The same examiner conducted the April 2021VA examination for muscle injuries, in which he diagnosed rupture of wrist-flexor tendon. He noted the Veteran's report of sudden pain in the left-wrist volar when lifting a case of beer soon after entering active service and that he underwent surgical repair of the ruptured tendon in 1972 and carpal tunnel surgical release in 1990. The examiner conducted extensive testing and examination. Regarding the claim for inflammatory soft tissue, the examiner opined that it is less likely than not that there is an established etiologic link between the Veteran's service, including presumed exposure to herbicide, and the Veteran's diagnosed left-wrist-tendon rupture. He explained in his rationale that the Veteran has a diagnosis of left-wrist-tendon rupture from a 1972 injury, it received surgical repair and the diagnosis is currently resolved. "As the injury occurred two years after release from active duty and per the veteran's report while lifting a case of beer, it is less likely than not that the diagnosis is related to the veteran's service, including presumed herbicide agent exposure. No diagnoses of inflammatory soft tissue disorders were identified other than Carpal Tunnel Syndrome (CTS), which is also resolved after surgical repair." He added that the record makes no mention of symptoms of carpal tunnel syndrome during the Veteran's period of service or until approximately 20 years after separation from active service. Moreover, the Veteran's carpal tunnel syndrome "is unilateral and localized to one joint, which would be an atypical presentation for a systemic inflammatory condition secondary to a chemical exposure," thereby making an established etiologic link less likely between service, including presumed exposure to herbicide, and the diagnosed carpal tunnel syndrome. Looking to the Veteran's lay statements, in his June 2021 correspondence statement, the Veteran notes his surgical removal of a Schwannoma from his left thumb and a neck cyst, both procedures noted above in the Board's summary of the record and noted by the April 2021 VA examiner. The Veteran further notes he underwent surgical repair in 1972 of ruptured left-wrist-flexor tendons. He adds the surgeon reported a generalized inflammation of the tendons and warned of peri-arthritic problems. In the statement accompanying his September 2013 Notice of Disagreement (NOD), the Veteran mentions soft-tissue lesions. As already stated above, the record reflects the Schwannoma removal, the neck cysts excision and the1972 left-wrist surgery. However, overall, the record from 2011 through 2021 does not show soft-tissue lesions, other than some findings for pustules, eruptions and comedones associated with the Veteran acne/chloracne disorder, for which he is already service connected. As it is, although the active-service medical record is devoid of any complaints, treatment or diagnoses of soft-tissue lesions or other disorders, the Veteran's above statements are nonetheless generally accurate. However, there is no evidence, either in the Veteran's statements or appearing in any treatment record which can link the above-reported soft tissue problems to any event, injury, illness, or disease in active service, to include exposure to an herbicide agent. Although presumptive service connection based on exposure to an herbicide agent is available under 38 C.F.R. § 3.309 (a) for soft-tissue sarcoma, the record offers no identification, treatment or diagnosis for that disorder. As already stated, the Veteran's claim for service connection remains in establishing service connection on a direct basis for exposure to an herbicide agent. See Combee v. Brown, 34 F.3d at 1042, 1043-44. The April 2021 examiner, in support of his opinion, when looking to the Veteran's carpal tunnel syndrome disorder and subsequent surgery as an example from the Veteran's history of soft-tissue inflammation, observed that that disorder is "unilateral and localized to one joint, which would be an atypical presentation for a systemic inflammatory condition secondary to a chemical exposure," thereby providing a clinically-based explanation of why an etiological link is less likely between any current soft-tissue disability and an event, illness or disease occurring in active service, including presumed exposure to an herbicide agent. The Board finds the Veteran competent to report his history of soft-tissue inflammations, especially given his medical training. The Board finds the VA opinion is the most informed piece of evidence in the file on the matter, because the examiner reviewed the full file, is a current licensed clinician, cited to accurate facts and provided sound rationale for the opinion provided. See Nieves-Rodriguez, 22 Vet. App. 295. For the reasons stated and based on the evidence of record the Board finds the preponderance of the evidence is against the claim for service connection on any basis. 4. Entitlement to TDIU prior to July 18, 2014. A finding of TDIU is appropriate "when there is present any impairment of mind or body 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), 4.15. Consideration may be given to the Veteran's level of education, special training and previous work experience in arriving at a conclusion, but not to age or to the impairment caused by non-service-connected disabilities. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16, 4.19. In reaching such a determination, the central inquiry is "whether the Veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). The record must reflect that circumstances, apart from non-service-connected conditions, place the claimant in a different position than other veterans having the same compensation rating. Put another way, assignment of a TDIU evaluation requires that the record reflect some factor which "takes the claimant's case outside the norm" of any other Veteran rated at the same level. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (citing 38 C.F.R. §§ 4.1, 4.15). The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A high rating in and of itself is recognition that the impairment makes it difficult to obtain or keep employment. The ultimate question is whether the veteran, in considering his or her service-connected disabilities, can perform the physical and mental acts required by employment, not whether he or she can find employment. Van Hoose, 4 Vet. App. at 363. Additionally, "substantially gainful employment" is defined as an occupation that provides an annual income that exceeds the poverty threshold for one person, irrespective of the number of hours or days that a veteran actually works and without regard to the veterans earned annual income. See Faust v. West, 13 Vet. App. 342 (2000). Marginal employment is not considered substantially gainful employment and generally is deemed to exist when a veteran's earned income does not exceed the amount established by the United States Department of Commerce, Bureau of the Census, as the poverty threshold for one person. Marginal employment may also be held to exist in certain cases when earned annual income exceeds the poverty threshold on a facts-found basis. Marginal employment, odd-job employment and employment at half the usual remuneration is not incompatible with a determination of unemployability if the restriction to securing or retaining better employment is due to disability. See 38 C.F.R. § 4.17 (a). Total disability ratings for compensation may be assigned when the schedular rating is less than total and when the disabled person is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that, if there is only one such disability, that disability shall be ratable at 60 percent or more. If there are two or more such disabilities, there shall be at least one disability ratable at 40 percent or more and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16 (a). The combined rating is achieved by "adding" the disability ratings together. However, this is not a conventional addition of numerical values. The efficiency of the individual for employment purposes is not reflected as a numerical value equivalent to the assigned disability rating; in terms of actual efficiency, the number will be lessened under the regulation. However, VA recognizes that earning capacity is affected exponentially as a less severe service-connected disability is added to the most severe service-connected disability, thereby reflecting the ever-diminishing efficiency of the individual. See 38 C.F.R. § 4.25. The United States Court of Appeals for the Federal Circuit has held that determination of whether a veteran is unable to secure or follow a substantially gainful occupation due to service-connected disabilities is a factual rather than a medical question and that it is an adjudicative determination properly made by the Board or the VA Regional Office. See Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013). The Veteran's service-connected disabilities, employment history, education and vocational attainment, and all other factors bearing on the issue will be considered. 38 C.F.R. §§ 3.341, 4.16 (b), 4.19. The Board has reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to review the entire record, the Federal Circuit has held that the Board does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate and the Board's analysis below will focus specifically on what the evidence shows or fails to show as to the claims. During the period prior to July 18, 2014, the Veteran has been service connected for post-traumatic stress disorder (PTSD) at 50 percent disability, tinnitus at 10 percent, bilateral hearing loss at a noncompensable rating and both hypertension and chloracne also at noncompensable ratings from October 30, 2012. The Veteran's combined rating prior to July 18, 2014 is 60 percent. However, this combined rating does not satisfy the regulatory threshold for TDIU, set forth above, of 2 or more disabilities, with 1 disability ratable at 40 percent or more and sufficient additional disability from others to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16 (a). That notwithstanding, it is the policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of a service-connected disability shall be rated totally disabled. 38 C.F.R. § 4.16 (b). Therefore, although the schedular criteria for TDIU, as set out in 38 C.F.R. § 4.16 (a), are not met, a total rating on an "extraschedular" basis nonetheless may be granted in exceptional cases (and pursuant to specifically prescribed procedures) when a Veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities. 38 C.F.R. § 4.16 (b). Therefore, to accord justice in the exceptional case when the schedular ratings are found to be inadequate, the Director of the Compensation Service, upon field station submission, is authorized to approve an extraschedular rating commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities. Neither the Regional Office (RO) nor the Board is permitted to assign an extraschedular rating in the first instance. Floyd v. Brown, 9 Vet. App. 88, 95 (1996)). However, the Board may review the later determinations of the Director. Anderson v. Shinseki, 22 Vet. App. 423, 427 (2009). The Board will briefly note that service-connected tinnitus is ratable at the sole evaluation of 10 percent. As the maximum rating allowed, this evaluation suggests little or no impact on function as it might relate to occupational performance. Moreover, the Board has reviewed the record pertaining to tinnitus and it provides no relevant findings for the claim of TDIU. Additionally, the medical evidence for bilateral hearing loss, hypertension and chloracne, rated at noncompensable ratings, provides no relevant findings, as the noncompensable ratings indicate no effects on function from any discernible symptoms. The Board notes that the Veteran's May 2015 Application for Increased Compensation Based on Unemployability (VA Form 21-8940) shows the Veteran became too disabled to work and last worked full-time sometime in 2004. The Veteran added that his disability affected full-time work in "August 2014." Although this date is not consistent with the 2004 date for when he last worked full-time, the Board will assume the 2014 date to be an error, either typographical or in the Veteran's understanding of what information was required. The Veteran also states in the Form 8940 that the service-connected disability preventing him from securing or following a substantially gainful occupation is/are "PTSD, chronic nausea/vomiting, stroke imbalance." The Veteran further states he worked as a part-time realtor at 20 hours per week from 1998 to 2006, adding he lost approximately 25 percent of work-time from illness. The Veteran also states he earned approximately $24,000.00 from real estate investments in the prior 12 months. It appears from another of the Veteran's statements on this form that his prior profession sometime before 1998 was as a chiropractor, but he gave no dates. Lastly, the Veteran indicates that he completed 4 years of college-level education and received training between 1972 and 2004 as a registered nurse (1972 1976), a chiropractor (1976 1980) and a realtor (1998 2004). The United States Department of Commerce, Bureau of the Census poverty threshold for one person in 2015 for persons 65 years and older was $11,367.00. See United States Census Bureau data, Poverty Thresholds, https://www.census.gov/data/tables/time-series/demo/income-poverty/historical-poverty-thresholds.html (last visited November 19, 2021). For comparison, in 2020, it was $12,413.00. Id. For prior to 2014, such earnings would not generally qualify as marginal employment under 38 C.F.R. § 4.16 (a). Turning to the record in the period prior to July 18, 2014, in an August 2011 visit to VA, the Veteran's PTSD screen was negative. A September 2011 VA primary care note shows the Veteran reported mid-cycle insomnia, nightmares, chronic anxiety, and some forgetfulness. He denied depression, suicidal ideations, hallucinations, delusions, or ability to concentrate. Mental status examination results were normal speech flow/content, euthymic mood, congruent affect, and no evidence of hallucinations, delusions or impaired judgment/insight. In the January 2013 VA examination for PTSD, the examiner diagnosed this disorder as chronic. He found occupational and social impairment, with a mental condition formally diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication. The examiner further found associated symptoms of depressed mood, anxiety and chronic sleep impairment. The Veteran reported past nightmares, flashbacks, irritability, current anger fits, depression, and stress sensitivity. The Veteran further reported he has no history of suicide attempts, no history of violent behavior, no alcohol-use problems, and no substance-use issues. The examiner found the Veteran has an intact psychosocial functional status. An October 2013 medical statement by Dr. A.J.A. states the Veteran has PTSD, with depression, anxiety, daily panic attacks, short term memory impairment, and disturbance in motivation mood. Looking to the Veteran's training during active service, the Board notes his military occupation specialty (MOS) required training in dental-technician school and field-medical-service school. The Veteran reported in the January 2013 examination for PTSD he was initially served as a steward, then after taking an examination was designated as a Medic (Corpsman), specifically working as a Dental Technician and later in Vietnam as a Field-Medical Technician assigned to the First Marine Air Wing. The Veteran's post-active-service eduction has been noted on the Form 8940, but the Veteran further reported in the January 2013 examination for PTSD he began college courses during active service and after discharge proceeded to utilize his educational benefits. After working as a laborer in a factory for approximately 1 year, he enrolled in a nursing program at PCC, in which he pursued a 2 year Associate's degree in nursing, he graduated in 1975 and after passing the board examinations in his state, was able to find employment as a Registered Nurse in various institutions. He enrolled at the WSCCM, completing his degree in August 1980, he passed the required civil service examinations and started his chiropractic practice in the 1980s, retiring in 2000. He later became a real estate broker for 2 to 3 years. Looking to the Veteran's lay statements, in the statement accompanying the Veteran's August 2013 Notice of Disagreement, the Veteran contends he suffers from PTSD, with frequent panic attacks, memory loss, social difficulties, loss of sleep, and anxiety. He further contends that these symptoms, with his other disorders of chronic nausea and vomiting, gastroparesis and hyperplasia, render him unemployable. In a November 2013 correspondence statement, the Veteran states he is impaired due to daily panic attacks, disturbance in mood and motivation, social difficulty, and short-term memory deficits. The Veteran is competent and credible in his report of employment history. However, his service-connected PTSD in the period prior to July 18, 2014 did not preclude occupational and social tasks and responsibilities due to the severity of symptoms. Additionally, there is neither evidence of record nor reports or statements by the Veteran which direct the Board's attention to any aspect of the Veteran's overall disability picture which would warrant referral of a TDIU under § 4.16(b) for the time period on appeal. The Veteran was educated with a clinical background as well as clear success in the real estate field. The record fails to show a factor which takes his case outside the norm of other such veterans for the time period prior to July 18, 2014. Van Hoose, 4 Vet. App. at 363 citing 38 C.F.R. §§ 4.1, 4.15. The Board has considered the benefit-of-the-doubt doctrine; however, the Board does not perceive an approximate balance of positive and negative evidence. As the preponderance of the evidence is against the claims, the doctrine is not applicable and the claims must be denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3. EMILY TAMLYN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board P. Franke, 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.