Citation Nr: 21011942 Decision Date: 03/03/21 Archive Date: 03/03/21 DOCKET NO. 12-21 079A DATE: March 3, 2021 ORDER An initial 30 percent rating, and no higher, for gastroesophageal reflux disease (GERD), to include irritable bowel syndrome (IBS), acid reflux, and hiatal hernia is granted. Entitlement total disability rating based on individual unemployability (TDIU) prior to November 15, 2010 is granted. FINDINGS OF FACT 1. Since the grant of service connection and resolving benefit of the doubt in favor of the Veteran, his GERD disability manifested with persistently recurrent epigastric distress with dysphagia and pyrosis; the GERD symptoms did not more nearly approximate a combination of symptoms productive of severe impairment of health. 2. Resolving reasonable doubt in favor of the Veteran, his service-connected disabilities were of such nature and severity as to preclude him from securing or following substantially gainful employment prior to November 15, 2010. CONCLUSIONS OF LAW 1. The criteria for an initial 30 percent rating, and no higher, for GERD to include IBS, acid reflux, and hiatal hernia have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.16, 4.20, 4.27, 4.113, 4.114, Diagnostic Code (DC) 7346. 2. The criteria for entitlement to a TDIU prior to November 15, 2010 have been met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 3.400, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1969 to December 1971. These matters are before the Board of Veterans’ Appeals (Board) on appeal from the June 2010 and March 2016 rating decisions by a Department of Veterans Affairs (VA) Regional Office (RO). The June 2010 rating decision granted service connection for GERD, to include IBS, acid reflux, and hiatal hernia, and assigned an initial 10 percent disability rating. The March 2016 rating decision granted entitlement to a TDIU, effective November 15, 2010. The Board remanded the claim for a higher initial rating for the gastrointestinal disability in December 2014 and in November 2015. In September 2016, the Board remanded the issue of entitlement to an earlier effective date for a TDIU and denied a higher initial rating for the gastrointestinal disability. The Veteran appealed the decision to the United States Court of Appeals for Veterans Claims (Court). Pursuant to an April 2017 Joint Motion for Partial Remand (JMPR), the Court vacated the denial of the higher rating for the gastrointestinal disability. In October 2017, the Board remanded the issues on appeal. The Board denied the entitlement to higher rating for GERD and entitlement to a TDIU prior to November 15, 2010 in a September 2018 decision. The Veteran appealed this decision to the Court. Pursuant to a June 2020 memorandum decision, the Court vacated the Board’s decision, and remanded these matters for further action consistent with its terms. 1. An initial 30 percent rating, and no higher, for GERD, to include IBS, acid reflux, and hiatal hernia is granted. Disability ratings are determined by applying a schedule of reductions in earning capacity from specific injuries or a combination of injuries that is based upon the average impairment of earning capacities. 38 U.S.C. § 1155. Each disability must be viewed in relation to its entire history, with emphasis upon the limitations proportionate to the severity of the disabling condition. 38 C.F.R. § 4.1. When rating the Veteran’s service-connected disability, the entire medical history must be reviewed. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The Board must also fully consider the lay assertions of record. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). Where there is a question as to which of the two disability evaluations is applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence of record, any reasonable doubt remaining will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. Where the question for consideration is the propriety of the initial evaluation assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of “staged rating” is required. Fenderson v. West, 12 Vet. App. 119, 126 (1999). Staged ratings apply to both initial and increased rating claims. See Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). Conditions not specifically listed in the rating schedule may be rated by analogy under the DC for a closely related disease or injury. 38 C.F.R. §§ 4.20, 4.27. It will be permissible to rate under a closely rated disease or injury in which the functions affected, anatomical location, and symptomatology are closely analogous. 38 C.F.R. § 4.20; Lendenmann v. Principi, 3 Vet. App. 345 (1992). Service connection for GERD was granted in a June 2010 rating decision and assigned an initial 10 percent rating, effective May 11, 2009. The symptoms for GERD are rated under 38 C.F.R. § 4.114, DC 7346. He contends that the severity of his GERD symptoms warrants a higher rating. As there is no specific DC for GERD, the Veteran has been rated by analogy. By way of history, the Board found that § 4.114 and its DCs best encompassed the Veteran’s disability picture for GERD, in terms of symptoms and anatomical location for rating purposes. This is based on the Veteran’s reported symptoms of epigastric distress with symptoms of pyrosis (heartburn), regurgitation, gas, bloating, and vomiting; these symptoms mirrored the rating criteria found under DC 7346. Under DC 7346, a 10 rating is warranted if two or more of the symptoms for the 30 percent evaluation of less severity is shown. A 30 percent rating is warranted for persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. A 60 percent rating is warranted for symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. In evaluating the Veteran’s GERD, the Board may not deny entitlement to a higher rating due to relief provided by medication when those effects are not specifically contemplated by the rating criteria. See Jones v. Shinseki, 26 Vet. App. 56, 62 (2012); see also 38 C.F.R. § 4.114, DC 7346 (containing no reference to the effects of medication). Turning to the evidence of record, the Veteran’s VA treatment records from 2009 to 2010 did not address GERD or its symptoms. In March 2010, the Veteran underwent a VA esophagus and hiatal hernia examination. He reported onset in early 1970s and that most of his adult life he has had problems with GERD. He described taking omeprazole and had nausea and diarrhea on occasion from the medication. The Veteran had nausea several times a week, occasional dysphagia (less than once a week but at least monthly), esophageal distress several times a week accompanied by substernal pain. The pain was frequent and severe. He had pyrosis several times daily and regurgitated several times a week. There was mild hematemesis or melena about 1.5 years ago. The examiner found tenderness with palpation in the epigastric region. No malnutrition or significant weight loss was found. At a March 2010 VA examination for IBS, the Veteran stated he always had trouble with his stomach. He reported nausea occurred several times per week. Diarrhea occurred less than weekly, which lasted 1 day or less, but occurred more than 12 times in one year. There was intestinal pain that was sharp, occurred 1 to 2 hours weekly and felt severe in the lower abdominal area bilaterally. The examiner did not find partial bowel obstruction and found no signs of significant weight loss, malnutrition, or anemia. Abdominal tenderness was found in the epigastric area. The Veteran was examined in May 2010. He reported that he had nausea and diarrhea on occasion and his medication helps a great deal, but still has some problems. He had nausea several times a week, but no vomiting. He reported having occasional dysphagia (difficulty swallowing), which occurred less than once a week, but at least once a month. He had esophageal distress that occurred several times a week accompanied by severe substernal pain. The Veteran described regurgitation of bile-stained fluid that occurred several times a week. His heartburn occurred several times daily. A history of mild hematemesis or melena episode occurred about 2 years prior; but none was noted on this examination. No malnutrition or significant weight loss was noted. There were no other findings relating to the esophagus. The examiner found that the Veteran’s GERD symptoms had mild to moderate effect on his daily activities. The Veteran underwent another VA examination on July 9, 2012. He reported symptoms of heartburn and gas occurred about twice per week and experienced bloating about once per month. The Veteran reported that taking his medication helped him. On examination, the Veteran exhibited only signs of heartburn. There were no clinical findings of epigastric distress with dysphagia, esophageal stricture, spasms, acquired diverticulum, hematemesis, vomiting, or melena. The examiner reviewed the June 2010 computed tomography (CT) scan report and found it was negative for any findings related to GERD. The examiner found that his GERD did not impact his ability to work. The Veteran also underwent a VA examination for irritable bowel syndrome (IBS) in July 2012. He reported bloating that occurred once per month, “sometimes a little less.” He did not report symptoms of nausea or vomiting. There was no abdominal distress. He did not report weight loss, malnutrition, or any serious complications or general health effects. The examiner did not find that his IBS condition impacted his ability to work. VA treatment records from 2011 to 2014 showed he reported persistent bloating once in November 2013. The Veteran stated the bloating did not occur at every meal but was going on for months. He denied nausea, vomiting, changes in bowel movement or hematochezia. A May 2014 VA treatment record reflected the clinician’s note that his GERD was well-controlled. VA treatment records in 2015 showed that he denied having nausea, vomiting, diarrhea, and had no problems with choking. Pursuant to the November 2015 remand, the Veteran underwent VA examinations in February 2016 for his GERD, IBS, and esophageal conditions. The Veteran reported that he remained on medication for GERD, but now took medication as needed. He had soreness in the epigastric area, was bloated, and had gas. The bloating episodes will last 2 to 3 days at a time, every 3 to 4 months, and impaired his ability to work. He described having heartburn, had regurgitation at times, and infrequently would vomit. Consuming certain foods and beverages caused heartburn. Pertaining to GERD, the Veteran described infrequent episodes of epigastric distress, pyrosis, reflux, regurgitation, vomiting that occurred 3 times per year that lasted less than 1 day per episode, and sleep disturbances caused by reflux that occurred 4 or more times per year, which also lasted less than 1 day. He denied bowel disturbances, significant weight loss, malnutrition, esophageal stricture, spasm, or an acquired diverticulum. There was epigastric tenderness on examination. The examiner found there was no evidence of IBS or hiatal hernia present. The Veteran had mild epigastric and bilateral lower quadrant discomfort on palpation. The examiner noted that he was his VA treatment records show he was seen very infrequently for episodes of bloating, has required no continuous or chronic medication management, and has not sought treatment for ongoing symptoms. IBS was not listed as a current medical problem in his VA treatment records. The examiner found that these conditions did not impact his ability to work. By 2016, VA treatment records reflected the Veteran’s GERD was noted to be stable; he was not taking medication. A March 2016 note indicated GERD was stable. On examination, the clinician noted that his gastrointestinal system was soft, nontender, non-distended; no guarding or rebound tenderness; and active bowel sounds were present. An April 2016 treatment record showed the Veteran denied having nausea, vomiting, diarrhea, or difficulties swallowing. Pursuant to the JMPR and the October 2017 Board remand, the Veteran was afforded a VA examination for esophageal conditions in December 2017. The Veteran reported that since the last examination, he had GERD symptoms “on and off,” depending on what he ate and other circumstances. He reported pain in the epigastric area that usually lasted for a couple of hours, and relieved with medication. But he reported pressure and pain where he does not throw up, but “it’ll get up into your throat.” He had occasional gas or heartburn that disrupted his sleep and lasted about an hour before it resolved. The Veteran reported on infrequent occasions, he went to the emergency room for his bloating. His bloating may last 6 to 8 hours and sometimes cleared the next day. The Veteran also reported constipation and diarrhea. He mentioned that he has had these symptoms for years and that the diarrhea and constipation started a long time ago. He denied additional symptoms, limitations, or health impairments as for either GERD or IBS. The Veteran had symptoms of infrequent episodes of epigastric distress, heartburn, reflux, and substernal pain. He had mild epigastric tenderness upon palpation. The examiner found no esophageal stricture, spasm, an acquired diverticulum, significant weight loss or bleeding. A March 2017 CT scan revealed a small sliding hiatal hernia. No additional treatment was required other than his GERD medication (omeprazole for GERD and simethicone for IBS). His current hematocrit (red blood cell) count was at 46.7 percent, which the examiner noted was within normal limits. The examiner indicated no other diagnostic testing, imaging study, or laboratory testing would provide additional information regarding the severity of the Veteran’s GERD condition. There were no alarming symptoms present. His symptoms and testing results provide a full assessment of the severity of his condition. The examiner explained that this is because his symptoms were not described to be of a severity which would lead one to expect there to be any significant likelihood of additional abnormalities found. His symptoms are largely alleviated by avoidance of certain foods and drinks. The examiner also indicated that the Veteran did not have persistently recurrent epigastric distress, dysphagia, pyrosis, regurgitation, substernal arm or shoulder pain, vomiting, material weight loss, hematemesis, melena, and/or anemia. The examiner noted that the infrequent epigastric distress described just barely met the usual medical definition of epigastric distress, since he was easily able to manage his symptoms at home. The examiner explained, however, that this is because he is easily able to manage his symptoms at home by simply sitting down and taking his medication and allowing a few hours to pass before resuming normal activity. There was no considerable or severe impairment of health based on the current medical history, physical examination, and a review of his medical records. With respect to the Veteran’s IBS, the examiner found that the Veteran had alternating diarrhea and constipation. More often he had constipation, but neither is severe. He had intermittent bloating. There was no abdominal distress, weight loss attributable to an intestinal condition, or malnutrition found. The examiner also noted that continuous medication was required for control of the Veteran’s intestinal condition – omeprazole and simethicone. The examiner noted an August 2007 colonoscopy that revealed a benign 2 mm. polyp. After review, the Board finds that the December 2017 VA examination reports reflect substantial compliance with the directives set forth in the prior remand and the terms of the April 2017 JMPR. As the June 2020 memorandum decision did not discuss any inadequacies of this examination, a remand is not necessary, and the Board may proceed with adjudication. See Stegall v. West, 11 Vet. App. 268; D’Aries v. Peake, 22 Vet. App. 97, 106 (2008). Given the above and resolving reasonable doubt in favor of the Veteran, the Board finds that his GERD symptoms more nearly approximate an initial 30 percent rating, and no higher, since the effective date of the grant of service connection. A higher 30 percent rating requires GERD symptoms such as persistently recurrent epigastric distress with dysphagia (difficulty swallowing), heartburn, and regurgitation, accompanied by substernal or arm or shoulder pain productive of considerable impairment of health. The favorable evidence of record reflects the Veteran’s GERD has manifested with symptoms of esophageal distress several times a week accompanied by frequent and severe substernal pain, regurgitation that occurred several times a week, nausea several times a week, and heartburn occurring several times daily. These were symptoms noted at the March and May 2010 VA examinations that the Board has considered as “persistent” (defined as existing for a long or longer than usual time or continuously), due to their frequent nature of occurring several times daily or several times a week. See MERRIAM-WEBSTER, Persistent, https://www.merriam-webster.com/dictionary/persistent (last visited February 16, 2021). As these symptoms are persistently recurring and accompanied by substernal pain, the Board resolves doubt in his favor that they more nearly approximate the 30 percent rating criteria. The Board further finds that a 60 percent rating is not warranted for any period during the appeal. While the Board recognizes the Veteran reported pain, which is one of the symptoms listed in the 60 percent rating criteria, the other symptoms (i.e., vomiting, material weight loss and hematemesis or melena with moderate anemia) and severe impairment of health have not been shown between 2009 and July 2012. The March and May 2010 VA examination reports show that in the two years prior, the Veteran reported only having one single mild hematemesis or melena episode; none were found on examination. No malnutrition or significant weight loss was noted. As the objective evidence does not reflect severe impairment of health, a 60 percent rating is not warranted. The Veteran’s symptoms manifested with pyrosis and gas occurring twice per week and bloating about once per month. While this may be interpreted as persistently recurring, there was no substernal pain during this period (a 30 percent rating required persistently recurring “accompanied by”). There were no clinical findings of epigastric distress with dysphagia, vomiting, or regurgitation found during this period. This approximates more with the current 10 percent, where there is only one or two symptoms present. The Board has considered the November 2013 VA treatment where he reported bloating, but there, the Veteran reported that the bloating did not occur at every meal and about once a month; thus, this is considered intermittent and not persistently recurrent. They were not productive of considerable impairment of health, as there was no record of malnutrition, weight loss, or hematemesis or melena shown during this period. In 2016, the Veteran’s symptoms manifested with infrequent episodes of epigastric distress, pyrosis, regurgitation, and vomiting that occurred 3 times per year that lasted less than 1 day per episode. There was mild epigastric and bilateral lower quadrant discomfort on palpation. The examiner noted he was seen very infrequently for bloating. A March 2016 treatment record indicated GERD was stable. In sum, these symptoms were only present on occasion per the Veteran’s own report, and therefore is not shown to have been productive of severe impairment of health. There was no substernal pain found, only tenderness or soreness, and they were not productive of severe impairment of health. In 2017, the record reflected infrequent episodes of epigastric distress, heartburn, reflux, and substernal pain. The Veteran himself reported the GERD symptoms were “on and off” and that he had occasional gas or heartburn. Again, there were no impairments of health reports, as in, no malnutrition, weight loss, or hematemesis or melena was found. The 2017 examiner indicated the Veteran did not have persistently recurrent epigastric distress, dysphagia, pyrosis, regurgitation, vomiting, or substernal pain. The examiner noted the infrequent epigastric distress described barely met the medical definition of epigastric distress. The Veteran also reported only intermittent bloating at the 2017 IBS VA examination. The Board has considered the representative’s argument that the portion of the 2017 examination requiring continuous medication was ignored; however, the Board finds that even discounting any ameliorative effects of his medication, the evidence fails to reflect severe impairment of health such that a 60 percent rating is warranted. The Board has reviewed the medical and lay evidence and finds no indication that the Veteran’s gastrointestinal symptoms would cause severe impairment of heath or any of the symptoms indicated in the 60 percent rating criteria, even discounting his irregular use of medication for his symptoms. Indeed, the Veteran has reported that he tries to “not to take a lot of drugs, I try to take a health food supplement…I do take omeprazole, I take that as needed, they’ve got it on the instructions to take it every day but I take it every couple days, but it depends on what I eat and if I get stressed out or not whether I need it or not.” In sum, the Veteran’s GERD symptoms have not been productive of severe impairment of his health since the grant of service connection. At no time after this date has the Veteran shown malnutrition, weight loss, or anemia attributed to the service-connected gastrointestinal disorder. During this period, his symptoms manifested with infrequent episodes of epigastric distress, pyrosis, regurgitation, and vomiting, with at times, substernal pain. It can be said that the condition impacts his health, but not to a severe degree. As such, a higher 60 percent rating is not warranted. The Board has considered whether other diagnostic codes might apply to the Veteran’s symptoms. However, the Board notes that the Veteran’s IBS symptoms and effects of these conditions overlap with that of his GERD such as separate ratings are not warranted. 38 C.F.R. § 4.14; 38 C.F.R. § 4.113 (certain coexisting diseases of the digestive system in the abdominal area do not lend themselves to distinct and separate evaluations without violating the rules against pyramiding). In short, an initial 30 percent rating, and no higher, for GERD, to include IBS, acid reflux, and hiatal hernia, is warranted. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 2. Entitlement to a TDIU prior to November 15, 2010 is granted. The Veteran seeks entitlement to a TDIU prior to November 15, 2010. In its October 2017 decision, the Board determined that the Veteran had raised an informal TDIU claim in a February 23, 2004 statement. A formal application was received on January 12, 2015. Total disability ratings for compensation may be assigned when a veteran is unable to secure and follow a substantially gainful occupation. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. If the schedular rating is less than total, a total disability evaluation can be assigned based on individual unemployability if the Veteran is unable to secure or follow a substantially gainful occupation as a result of service connected disability provided that if there is only one such disability, this disability shall be ratable at 60 percent or more; if there are two or more 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 Veteran currently has an effective date of November 15, 2010, for a TDIU. The assignment was based on the date the Veteran’s service-connected disabilities met the schedular criteria set forth in § 4.16(a). The Veteran appealed from the March 2016 rating decision which granted TDIU and assigned the effective date. For the period prior to November 15, 2010, the Veteran is service-connected for PTSD (rated 50 percent from August 28, 2002); tinnitus (rated 10 percent from December 17, 2003); GERD to include IBS, acid reflux, and hiatal hernia associated with PTSD (rated 30 percent from May 11, 2009); and residuals of spontaneous pneumothorax, bilateral hearing loss, and erectile dysfunction associated with PTSD, which are all at a noncompensable rating. The combined rating is 60 percent from December 17, 2003; and 70 percent from May 11, 2009. The Veteran meets the criteria for award of a schedular TDIU effective May 11, 2009, but not prior. See 38 C.F.R. §§ 4.16(a), 4.25. Under 38 C.F.R. § 4.16(b), when a veteran fails to meet the percentage standards set forth in § 4.16(a), a total disability rating for compensation may be assigned when it is found that the service-connected disabilities are sufficient to produce unemployability. Such cases should be referred to the Director, Compensation Services, for extraschedular consideration. See 38 C.F.R. § 4.16(b). In October 2017, the Board remanded the issue of TDIU prior to November 15, 2010 to the Director of Compensation Service for a determination under 38 C.F.R. § 4.16(b) for the period prior to November 15, 2010. In June 2018, the Director declined to award TDIU on an extraschedular basis prior to November 15, 2010. Therefore, the Board may proceed to consider TDIU on an extraschedular basis. On his VA Form 21-8940, Application for Increased Compensation Based on Unemployability, he reported that he had last worked full-time in 2000, after which his service-connected bilateral hearing loss, PTSD, and GERD disabilities prevented him from working. The Veteran completed his first year of high school and received additional automotive training. He was last employed as a fence installer. The Veteran applied for disability benefits from the Social Security Administration (SSA) but was denied in June 1993. SSA records showed that the Veteran reported pain and swelling of joints in his elbows and hands and that kept him from doing manual labor. Therefore, he could no longer find work or sustain work because he has only performed manual labor work. His primary diagnosis was noted as rheumatoid arthritis and inflammatory polyarthropathies. Of note, these records included a letter penned by his physician, Dr. R.J.B. He opined that the Veteran’s rheumatoid arthritis is a progressive disease and most likely get worse. The Veteran should probably retrain in another field and most likely should be retrained in some job that will require minimal exertion of his upper extremities, to include his hands and elbows; this may include some kind of a desk job. Since the rheumatoid arthritis and inflammatory polyarthropathies are not service-connected disabilities, they may not be considered for TDIU purposes. A May 2003 VA treatment record showed he reported being unemployed since January 2003 after working in concrete construction, due to a torn ligament in his knee and a hernia, from lifting and straining. He reported he could not handle that kind of work anymore. He also reported that he had “problems with anger” and was “short-fused.” In an August 2003 VA psychiatry record, the Veteran reported that he quit working and had not followed through with vocational rehabilitation. The Veteran’s May 2003 statement reflects his report that he "[c]annot hold jobs. I had more than 75 jobs. . . . I feel tired, exhausted when I do not go to sleep. I cannot concentrate on anything, any time[]." A May 2003 finding by a medical examiner that the Veteran’s "concentration[is]poor.” At the March 2004 VA audio examination, the Veteran reported work experience in auto body and fender work, in construction, and in making and operating remote-controlled cars and airplanes. The examiner noted that the Veteran did not wear hearing aids at the time of examination but did not comment on functional impact. In an April 2004 statement, the Veteran contended that he has never been able to keep a job or have a relationship with his family and that he was mentally and physically tired. At his initial PTSD VA examination in June 2004, the Veteran reported that after service, he went to trade school for automotive body and fender work. He worked in this industry from 1971 until 1983 or 1984. The Veteran reported working at multiple manual labor jobs but could not keep a job; the longest he worked at a job was for two years. Symptoms caused no more than a slight impairment in social and occupational functioning. In a November 2004 VA treatment record, the clinician noted that the Veteran was experiencing some symptoms of depression and PTSD for years. He had been experiencing low energy levels and fatigue; low/ “lousy” interest in life activities; and had difficulties concentrating. A VA psychiatry record that same month showed that the Veteran reported being irritable, anxious, and depressed. He kept himself busy by working on his property. The Veteran had a subsequent VA audio examination in February 2006, where he reported similar work experience as the 2004 examination. A March 2007 VA treatment record showed the Veteran reporting working at cutting work, hauling wood, etc. The Veteran underwent a VA examination in April 2007 for his pneumothorax condition. After service, he reported working in a body and fender shop for 15 years, but stopped after the exposure to paint thinners, dust, and fumes affected his lungs. Then he worked in concrete construction. He reported that due to the difficulties he had with his shoulders, arms, and his arthritis, he had to leave that job. The examiner described his functional limitations, but none of them were attributed to his service-connected conditions at the time. VA treatment records in July 2007 reflect that he was working on a cattle farm. The October and November 2007 treatment records reflect that the Veteran obtained a job working as a part-time sales clerk at a knife shop and was working 25-30 hours. At the December 11, 2008, PTSD VA examination, the examiner noted that he used to perform auto body work and worked in construction. The Veteran reported finding it difficult to work due to problems with his knee, fatigue, and PTSD symptoms. He felt much more at ease being by himself and away from people. He reported not unemployed but not retired and that he had not been working for 5 to 10 years. The examiner found that his PTSD symptoms resulted in deficiencies in thinking, but not in judgment. His symptoms also resulted in deficiencies in family relations, work, mood, or school. The June 2009 PTSD VA examiner found that the Veteran’s unemployment seems related to effects of PTSD and subsequent polysubstance abuse and noted the following PTSD effects: poor concentration cause difficulty completing work, and recurrent thoughts make it difficult to stay focus on various tasks and to relate appropriately with others. The examiner noted that if he continued the treatments in addition to medication, then his prognosis is fair for coping with PTSD symptoms. The April 2010 VA audio examiner found that the Veteran had normal to moderately severe hearing with very good speech discrimination bilaterally. At the April 2010 VA examination for erectile dysfunction, the examiner noted that the Veteran previously worked as a construction worker. He was unemployed due to overall health conditions. The Veteran reported that he was unemployed due to overall health conditions at the May 2010 VA GERD examination. The examiner found the Veteran’s GERD symptoms had mild to moderate effect on his daily activities. The December 2010 PTSD VA examination report reflected that the Veteran was not currently employed. The Veteran did not contend that his unemployment was due to the effects of the mental disorder. At the examination, the Veteran reported short-term moderate memory impairment on a daily basis. He reported difficulties remembering appointments, holidays, or why he drove into town. He had mild panic attacks that lasted one minute in duration and occurred 2 to 3 times per months, but that they did not affect independent functioning. The Veteran becomes more socially withdrawn when depressed and more anxious when he is around people. The examiner found that his sleep impairment caused him to be tired during day and resulted in poor concentration. The examiner also found that his recurrent intrusive thoughts, poor concentration, flashbacks, memory impairment and impaired concentration interfered with his work. The Veteran’s PTSD symptoms caused reduced reliability and productivity. After review and resolving benefit of the doubt to the Veteran, the evidence reasonably reflects his service-connected disabilities rendered him unemployable as of February 2004. On the Veteran’s VA Form 21-8940, he reported that he last worked on a full-time basis in 2000. He indicated his highest level of education was one year of high school. Regarding the nature of his employment, the evidentiary records reflects that he worked in manual construction or physical labor capacities. The record reflects that between 2004 to 2010, the Veteran was able to obtain and sustain some very limited and infrequent employment, such as working at cutting work or hauling wood, or working on a cattle farm, and as a sale clerk at a knife shop at least between 2007-2008. The March 2007 VA treatment record showed the Veteran reporting working at cutting work and hauling wood, but it is not clear from the record whether the Veteran was employed or merely working on his property. He appears to have been working a cattle farm in July 2007, but by October 2007, VA treatment records show he reported working as a part-time (25-30 hours) as a salesclerk at a knife shop. His earnings and salary throughout 2007 are unclear. However, at the December 2008 PTSD VA examination, the Veteran reported he was unemployed and had not been working for 5 to 10 years. Thus, it appears any employment he had in 2007 was limited, inconsistent, and infrequent. The evidentiary record reflects that the Veteran had difficulties with employment due to problems he had with his nonservice-connected physical disabilities that affected his shoulders, arms, and his arthritis. Indeed, SSA records reflect employment difficulties due to rheumatoid arthritis and inflammatory polyarthropathies, which are nonservice-connected disabilities. While it is observed that he reportedly had to leave his job in concrete construction in 2003 due to after working in construction, due to a torn ligament in his knee and a hernia from lifting and straining, he did report some psychiatric disturbances as well. In 2004, a VA clinician noted that the Veteran had been experiencing some symptoms of depression and PTSD for years. He had been experiencing low energy levels and fatigue; low/ “lousy” interest in life activities, and had difficulties concentrating. The December 2008 VA examiner determined that the service-connected PTSD symptoms resulted in occupational impairment, with deficiencies in thinking, work and mood. The June 2009 PTSD VA examiner likewise found that the Veteran’s unemployment seems related to effects of PTSD including poor concentration causing difficulty completing work and recurrent thoughts make it difficult to stay focus on various tasks and to relate appropriately with others. In addition to the occupational impairment from the service-connected PTSD, the Veteran’s gastrointestinal conditions, which are service-connected effective May 2009 have been considered. In this regard, the Veteran’s prior employment history shows that most of his jobs involved intense physical labor. His service-connected gastrointestinal conditions are noted to have had a moderate effect on his activities and regularly require him to sit down and allow a few hours to pass before resuming normal activity. Resolving all reasonable doubt in the Veteran’s favor, the probative evidence demonstrates that the combined effects from his service-connected PTSD and gastrointestinal disability reasonably prevented him from securing or following substantially gainful employment throughout the entire appeal period under review, which is prior to November 15, 2010. Entitlement to a TDIU prior to November 15, 2010 is granted. 38 U.S.C.§ 5107; 38 C.F.R. §§ 3.102, 4.3, 4.16. D. JOHNSON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Tang, 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.