Citation Nr: 18160162 Decision Date: 12/27/18 Archive Date: 12/26/18 DOCKET NO. 17-06 106 DATE: December 27, 2018 ORDER Service connection for tinnitus is granted. Entitlement to an initial rating of 30 percent, but no higher, for service-connected other specified trauma and stress related disorder is granted, subject to the laws and regulations governing the award of monetary benefits. REMANDED Entitlement to service connection for a left thumb condition is remanded. Entitlement to service connection for bilateral hearing loss is remanded. FINDINGS OF FACT 1. Resolving reasonable doubt in his favor, the Veteran's currently diagnosed tinnitus manifested during, or as a result of, active military service. 2. The Veteran's other specified trauma and stress related disorder has been manifested by recurrent avoidance and intrusive symptoms, such as involuntary and intrusive distressing memories and dreams of the traumatic event; chronic sleep impairment; anxiety; hypervigilance; concentration issues; mild memory loss; and panic attacks that occur weekly or less often. 3. Resolving reasonable doubt in the Veteran’s favor, his psychiatric symptoms more nearly approximate the degree of occupational and social impairment contemplated by a 30 percent schedular rating, but no higher. CONCLUSIONS OF LAW 1. The criteria for establishing entitlement to service connection for tinnitus have been met. 38 U.S.C. §§ 1110, 1131, 5103(a), 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 2. The criteria for an initial rating of 30 percent, but no higher, for service-connected other specified trauma and stress related disorder have been met. 38 U.S.C. §§ 1155, 5107 (West 2012); 38 C.F.R. § 4.130, Diagnostic Code 9413 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Navy from October 1982 to October 1989. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a Department of Veterans Affairs (VA) Regional Office (RO) rating decisions in November 2014 and January 2015. The Veteran perfected an appeal. See April 2015 Notice of Disagreement (NOD); December 2016 Statement of the Case (SOC); January 2016 SOC; January 2017 VA Form-9. Service Connection Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C. 1110, 1131; 38 C.F.R. 3.303 (a). Establishing service connection generally requires (1) evidence of a current disability; (2) evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F. 3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (table); 38 C.F.R. § 3.303. Service connection may also be granted for any disease diagnosed after the military discharge, when all the evidence, including that pertinent to the period of military service, establishes that the disease was incurred during the active military service. 38 U.S.C. § 1113 (b); 38 C.F.R. § 3.303 (d). A lay witness is competent to testify as to the occurrence of an in-service injury or incident where such issue is factual in nature. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). Additionally, where symptoms are capable of lay observation, a lay witness is competent to testify to a lack of symptoms prior to service, continuity of symptoms after in-service injury or disease, and receipt of medical treatment for such symptoms. Charles v. Principi, 16 Vet. App 370, 374 (2002). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the Veteran. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. at 53. 1. Tinnitus The Veteran seeks entitlement to service connection for tinnitus. He contends that he developed the condition as a result of noise exposure related to his military occupational specialty (MOS) as an electrical/mechanical equipment repairman. As an initial matter, the Board notes that the Veteran has a current diagnosis of tinnitus. See September 2014 VA Examination Report. Thus, the Veteran has satisfied the first Shedden requirement of a current disability. Additionally, VA has found that the Veteran’s MOS showed a high probability for noise exposure. Thus, the Veteran's noise exposure is conceded and the second element of service connection is met. See Shedden, 381 F.3d at 1166-67. Turning to the question of whether there is a nexus, or link, between the current shown disability and service, the evidence indicates that the Veteran’s tinnitus had its onset in service. The Veteran has asserted that his tinnitus is constant and may have begun in service. The Board acknowledges that the September 2014 VA examiner opined that the Veteran’s tinnitus was less likely as not caused by or a result of noise exposure while in service. The examiner based his opinion on electronic hearing testing at enlistment, during service, and at discharge which did not show significant threshold shifts in hearing acuity beyond normal variability/progression while in service. However, given the inherently subjective nature of tinnitus, the Veteran is uniquely situated to competently identify and report on the onset and duration of ringing in the ears. A lay person is competent to provide an opinion on the presence of recurrent ringing in the ears since service, as the symptom is capable of lay observation. See Charles v. Principi, 16 Vet. App. 370, 374 (2002) (noting that the veteran testified that he experienced ringing in his ears in service and that he experienced such ringing ever since service, and finding that the veteran was competent to so testify because ringing in the ears was capable of lay observation). As such, the Board places probative weight on the Veteran's statements regarding in-service onset of his tinnitus. See Charles v. Principi, 16 Vet. App. 370 (2002). As the evidence of record stands in relative equipoise, the benefit of the doubt is resolved in favor of the Veteran. Service connection for tinnitus is warranted. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. Increased Rating Disability ratings are determined by the application of VA's Schedule for Rating Disabilities. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155 (2012); 38 C.F.R. § Part 4 (2017). Ratings for service-connected disabilities are determined by comparing the Veteran's symptoms with criteria listed in VA's Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. The veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Here, the relevant evidentiary window begins one year before the Veteran filed his claim for an increased rating, and continues to the present time. The Board will also consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Hart v. Mansfield, 21 Vet. App. 505 (2007). When there is a question as to which of two ratings to apply, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating, otherwise the lower rating shall be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2017). 2. Other Specified Trauma and Stress Related Disorder The Veteran seeks a higher initial rating for his service connected other specified trauma and stress related disorder, currently evaluated as 10 percent disabling, and rated under 38 C.F.R. § 4.130, Diagnostic Code 9413. Diagnostic Code 9413, is evaluated under the General Rating Formula for Mental Disorders. Under this formula, a 10 percent rating is assigned when there is occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication. 38 C.F.R. § 4.130. 30 percent rating is assigned where there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). Id. A 50 percent rating is assigned when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped, speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent evaluation is warranted where there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. Id. A 100 percent evaluation is warranted where there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. The symptoms listed in VA's general rating formula for mental disorders are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). The United States Court of Appeals for the Federal Circuit (Federal Circuit) in Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-117 (Fed. Cir. 2013), however, noted the "symptom-driven nature" of the General Rating Formula, and observed that "a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration." According to the applicable rating criteria, when evaluating a mental disorder, the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission must be considered. 38 C.F.R. § 4.126 (a). In addition, the evaluation must be based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. Id. Further, when evaluating the level of disability from a mental disorder, the extent of social impairment is considered, but the rating cannot be assigned solely the basis of social impairment. 38 C.F.R. § 4.126 (b). Turning to the evidence of record, VA medical records reflect that the Veteran was hospitalized with suicidal ideation at the Denver VA Medical Center (VAMC) in May 2013. During that admission, he was diagnosed with major depressive disorder (MDD). Following his hospitalization, the Veteran continued with outpatient therapy at the Denver VAMC. An October 2013 psychotherapy session note documents that the Veteran was administered a PCL test on which he scored 72, which would put him in the severe range for PTSD. PTSD was subsequently added as a diagnosis at the Denver VAMC. In September 2014, the Veteran was afforded a VA initial PTSD examination. The examiner noted the diagnosis of PTSD, but stated that the PCL test is a screening tool that relies entirely on self-report and is not by itself sufficient basis for making a diagnosis of PTSD. The examiner diagnosed major depressive disorder that was less likely as not caused by, or a result of, military service. He also reported a diagnosis of PTSD which was at least as likely as not caused by or a result of fear of hostile military or terrorist activity. In remarking on the severity of the Veteran’s diagnoses, the examiner noted that there were mental disorder signs and symptoms that resulted in deficiencies in most of the following areas: work, school, family relations, judgment, thinking, and mood. It was further noted that the Veteran had continuing difficulty with mild memory loss, chronic sleep impairment, anxiety, depressed mood, disturbances of motivation and mood, and recurrent suicidal ideation. The Veteran’s symptoms required continuous medication. See September 2014 VA Initial PTSD Examination. The examiner noted that the veteran reported difficulty with nightmares and some possible mood disturbance when stationed aboard the USS John F. Kennedy, which was deployed in response to the bombing of the Marine barracks in Beirut, Lebanon. During a mission off the aircraft carrier, a pilot from the Veteran’s squadron was shot down and killed. The Veteran gave a history that indicated that he was having intrusive symptoms, including nightmares, that began at that time and some sleep disturbance which the examiner stated would be indicative of elevated arousal. However, the examiner reported that he did not find that the Veteran met all criteria for PTSD at that time or subsequently. The examiner noted that there were some mild suggestions of avoidance symptoms, but that considering all the reported symptoms together, the Veteran’s condition did not meet the diagnostic criteria for PTSD. Id. Nonetheless, the examiner stated that, accepting that the Veteran was having a significant psychological response to the death of the pilot from his squadron during a combat operation, his symptoms would most closely fit the criteria for other specified trauma and stress-related disorder. Per the Veteran’s history, the examiner noted that he had improvement in symptoms or complete remission of symptoms following discharge from military service. In this regard, the Veteran reported that from about 1990 – 2008, his life was very happy and he was content with his marriage, family, and work. He did not experience significant psychological symptoms again until approximately 6 years prior to the examination, following iatrogenic problems related to a surgery and other medical problems. The Veteran suffered from chronic pain since that time and was diagnosed and treated for MDD at the Denver VAMC. The examiner noted that it was clear from his description that this included psychotic features in the form of auditory hallucinations. The examiner opined that it was at least as likely as not that the Veteran’s MDD had developed secondary to his significant chronic medical problems. It was noted that with the emergence of the MDD, the Veteran was now experiencing nightmares which included content about the death of the squadron pilot in service. As the Veteran functioned well for a period of at least 18 years from 1990 – 2008, absent of any significant psychological symptoms and absent of any occupational or social impairment, the examiner stated that his current level of impairment could be attributed directly to the MDD with psychotic features that had developed since the emergence of his chronic medical problems. Id. The examiner reported that following as symptoms that actively applied to the Veteran’s diagnoses: depressed mood; anxiety; panic attacks that occurred weekly or less often; chronic sleep impairment; difficulty in understanding complex commands; disturbances of motivation and mood; difficulty in adapting to stressful circumstances, including work or a worklike setting; and suicidal ideation. Id. Following the September 2014 VA examination, the RO requested clarification of conflicting medical evidence in the record. The RO noted that the VA examiner diagnosed major depressive disorder and other specified trauma and stress-related disorder. In this regard it was noted that the stress disorder had been related to service and the Veteran’s confirmed stressor, however the depressive disorder had not been related to service. The RO requested clarification as to the symptomatology due to the stress disorder, to exclude any symptomatology due to the depressive disorder. It was further noted that in a November 2014 addendum, the VA examiner stated that “all symptoms and severity were due to the MDD.” However, the September 2014 examination findings stated that the Veteran “reports that he continues to have frequent nightmares about Lt. Commander Lange” and that there were some “mild suggestions of avoidance symptoms” and that “intrusive symptoms are due to other specified trauma and stress-related disorder. All other symptoms due to MMD.” The RO further noted that the symptoms due to both disorders listed in Section 5 of the September 2014 DBQ included depressed mood; anxiety; panic attacks that occurred weekly or less often; chronic sleep impairment; difficulty in understanding complex commands; disturbances of motivation and mood; difficulty in adapting to stressful circumstances, including work or a worklike setting; and suicidal ideation. Thus, the RO requested clarification as to which of the symptoms listed in Section 5, if any, should be properly described as “intrusive symptoms” due to the trauma disorder. Clarification was provided in a January 2015 VA examination note. The examiner remarked that, upon reviewing the September 2014 initial PTSD report, a number of symptoms were listed under the Veteran’s diagnosis of other specified trauma and stress-related disorder, including avoidance and intrusive symptoms. She explained that these symptoms were noted as recurrent, involuntary, and intrusive distressing memories of the traumatic event, and recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s). The examiner noted that this second symptom refers to nightmares, which would also indicate chronic sleep impairment. Thus, the diagnosis of other specified trauma and stress-related disorder would include symptoms listed under Section 5 of anxiety, panic attacks that occur weekly or less often, and chronic sleep impairment. Given that concentration issues were noted in the report and that the Veteran received an impaired score on the MOCA, the examiner indicated that mild memory loss should also be listed under Section 5. The examiner noted that the above clarification was based on the Veteran’s military records, review of the c-file, treatment records, review of clinical evaluation, review of recent research, and the DSM-V diagnostic criteria. See January 2015 Examination Note. A mental disorders DBQ was provided in January 2017. The examiner noted diagnoses of service-connected other specified trauma and stress-related disorder and severe recurrent major depressive disorder which was secondary to post-military medical problems and resulting physical limitations. Symptoms attributable to other specified trauma and stress related disorder were noted as nightmares. The examiner indicated that all other psychological symptoms were attributable to the major depressive disorder. He noted that MDD was unrelated to the other specified trauma and stress related disorder. Overall, the Veteran displayed occupational and social impairment with reduced reliability and productivity. The examiner indicated that 10 percent of the indicated level of occupational and social impairment was attributable to the Veteran’s other specified trauma and stress related disorder, while the remaining 90 percent was attributable to the Veteran’s major depressive disorder. The examiner noted that the following symptoms actively applied to the Veteran’s diagnoses: depressed mood; anxiety; panic attacks that occur weekly or less often; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; chronic sleep impairment; mild memory loss, such as forgetting names, directions, or recent events; flattened affect; disturbances of motivation and mood; difficulty in adapting to stressful circumstances, including work or a work like setting; and suicidal ideation. See January 2017 VA Examination. In his behavioral observations, the examiner noted that the Veteran presented a clean, casual appearance, with a relaxed posture. The Veteran was cooperative with evaluation and presented as a reliable historian without evidence of exaggeration or minimization. The Veteran had appropriate eye contact and evidenced psychomotor retardation. He was articulate with slowed rate of speech and a restricted affect. The Veteran’s mood was dysphoric and congruent with his thought content. The Veteran was occasionally tearful, but displayed logical, goal-directed organization of thought and did not evidence hallucinations or delusions. The Veteran evidenced preoccupation with his poor health and resulting physical limitations. Id. In noting other symptoms attributable to the Veteran’s mental disorders, the examiner noted that the Veteran reported chronic depression for the past 6 years with daily crying; sense of worthlessness; little interest or pleasure in previously enjoyed activities; decreased sleep due to pain; irritability; decreased appetite; difficulty with concentration and decision-making; and lack of libido. The Veteran reported feeling “stressed” due to “not being able to do, to provide,” and he reported worry about “not keeping my wife happy, what other people think about me.” The Veteran endorsed fleeting passive and active suicidal ideation with the last fleeting active thoughts having occurred 2-3 weeks prior and brought on by getting hit by a car. The Veteran reported that he felt better once talking with his wife or a friend. The Veteran reported sleep interfered by pain and thoughts of worthlessness. He reported little dream recall except for nightmares 2-3 times per month that awaken him in panic. The Veteran also endorsed inattentiveness and forgetfulness. The examiner indicated that the Veteran should be considered an increased but not current imminent risk. Id. After thorough consideration of the evidence, the Board finds that the Veteran's symptoms overall more closely approximate the criteria for a 30 percent disability rating, but no higher, since the date of the claim. See 38 C.F.R. § 4.130, Diagnostic Code 9413. The evidence indicates that the Veteran has diagnoses of service-connected other specified trauma and stress related disorder and major depressive disorder which has been found to be unrelated to service. Although the record contains at times conflicting evidence as to which of the Veteran’s symptoms may be attributed to each diagnosis, the Board finds that the Veteran’s service-connected other specified trauma and stress related disorder is manifested by recurrent avoidance and intrusive symptoms, such as involuntary and intrusive distressing memories and dreams of the traumatic event; chronic sleep impairment; anxiety; hypervigilance; concentration issues; mild memory loss; and panic attacks that occur weekly or less often. The Veteran’s September 2014 initial PTSD examination was somewhat confusing regarding which symptoms were attributed to the Veteran’s diagnosed stress related trauma disorder. Clarification was provided in the January 2015 addendum opinion which found that the following symptoms could be attributed to the Veteran’s other specified trauma and stress related disorder: avoidance and intrusive symptoms noted as recurrent, involuntary, and intrusive distressing memories of the traumatic event, and recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s); nightmares, which would also indicate chronic sleep impairment; and mild memory loss, as indicated by concentration issues noted in the report and an impaired score on the MOCA. Additionally, the January 2015 examiner found that symptoms listed under Section 5 of anxiety, panic attacks that occur weekly or less often, and chronic sleep impairment could be attributed to the other specified trauma and stress-related disorder. The January 2017 VA examiner reported that only nightmares were associated with the Veteran’s other specified trauma and stress related disorder. However, he noted continued symptoms of anxiety; panic attacks that occur weekly or less often; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; chronic sleep impairment; and mild memory loss, such as forgetting names, directions, or recent events. Thus, the record establishes a consistent set of symptoms, as detailed above, that have been attributed to the Veteran’s other specified trauma and stress related disorder. While there has been disagreement between the examinations of record as to which of these symptoms are properly attributed to the Veteran’s service-connected psychiatric disability, the Board resolves reasonable doubt in the Veteran’s favor and finds that his other specified trauma and stress related disorder has been manifested by the aforementioned symptoms for the entirety of the appeal period. Thus, the Board finds that the Veteran’s symptoms and the effect on his functioning more nearly approximate the criteria contemplated by a 30 percent disability rating. Accordingly, after resolving all reasonable doubt in favor of the Veteran, a 30 percent evaluation, is assigned from October 7, 2012. 38 C.F.R. § 4.7. There is, however, no persuasive evidence that the Veteran’s other specified trauma and stress related disorder has been manifested by symptoms that more nearly approximate the criteria for a 50 percent disability rating. The Board acknowledges that the Veteran’s overall psychiatric condition results in occupational and social impairment with reduced reliability and productivity. Further, the Veteran displays many of the symptoms associated with a 50 percent rating. However, as discussed at length above, such symptoms and occupational and social impairment have been attributed to the Veteran’s non-service connected major depressive disorder. As such, the evidence does not demonstrate that the Veteran’s other specified trauma and stress related disorder, in and of itself, is manifested by occupational and social impairment with reduced reliability and productivity. Thus, a higher evaluation of 50 percent is not warranted. The Veteran is competent to provide evidence about his disability; for example, he is competent to describe symptoms related to his acquired psychiatric condition. See Layno v. Brown, 6 Vet. App. 465 (1994). He is also credible to the extent that he sincerely believes he is entitled to a higher rating. However, he is not competent to identify a specific level of disability according to the appropriate Diagnostic Code. Competent evidence concerning the nature and extent of the Veteran's mental disorder was provided by the VA examiners who have interviewed and evaluated him during the current appeal. The medical findings as provided in the various VA examination reports directly address the criteria under which this disability is evaluated. Thus, the competent lay evidence is outweighed by the competent medical evidence that evaluates the true extent of his disabilities. The Board realizes that the symptoms noted in the rating criteria are not intended to be an exhaustive list, but are examples of the types and severity of symptoms that indicate a certain level of disability. Thus, although the Veteran has endorsed some symptoms indicative of higher disability ratings, the Board believes that based on the overall record, including the Veteran's lay statements and VA treatment records and examination reports, the frequency, duration, and severity of his acquired psychiatric disorder are most consistent with a 30 percent disability rating. REASONS FOR REMAND Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran's claim so that he is afforded every possible consideration. 38 U.S.C. § 5103A (West 2012); 38 C.F.R. § 3.159 (2017). 1. Left Thumb Condition The Veteran seeks service connection for a left thumb condition which he contends is the result of an in-service injury. The Veteran was provided a VA wrist conditions examination in September 2014. The examiner noted that in March 1985, the Veteran injured his left wrist and thumb by swinging a sledgehammer onto a board, resulting in a fracture. The examiner noted that residuals of the injury had remained and included symptoms of constant pain and numbness to the left wrist and thumb. It was noted that 1 – 2 times per month, the Veteran’s left thumb locks into a muscle contraction for 1 – 10 minutes. Imaging studies of the wrist were not performed. See September 2014 Wrist Conditions Disability Benefits Questionnaire. The Board notes that the remainder of the DBQ pertained to the Veteran’s left wrist condition. The examiner found that the Veteran’s left wrist condition was at least as likely as not incurred in or caused by the claimed in-service injury. As rationale, the examiner noted that the Veteran reported no history of left wrist/thumb injury, nor conditions, prior to service. She noted service medical records from November 1986 which contained clinical notes for a bilateral wrist injury. Id. In a November 2014 rating decision, the RO granted service connection for the Veteran’s left wrist fracture, but denied service connection for the left thumb condition. The RO stated that the evidence did not show an event, disease, or injury in service; that service treatment records contained no complaints, treatment, or diagnosis of this condition; and that the evidence did not show a current diagnosed disability. See November 2014 Rating Decision. However, based on the report of the September 2014 VA examiner, the Board finds that there is an indication that the Veteran has a current left thumb disability, and suggestion that such condition is related to the same in-service injury which formed the basis for the Veteran’s service-connected left wrist fracture. The Board acknowledges that the September 2014 examiner did not render a separate diagnosis of a left thumb condition. However, given the examination findings, the Board finds that an addendum medical opinion is warranted to determine whether the Veteran has a current left thumb disability which was incurred in, caused by, or due to service, to include the March 1985 injury in which the Veteran injured his service-connected left wrist. 2. Bilateral Hearing Loss The Veteran contends that he has bilateral hearing loss as a result of noise exposure related to his military occupational specialty (MOS) as an electrical/mechanical equipment repairman. As an initial matter, the Board notes that VA has found that the Veteran’s MOS showed a high probability for noise exposure. As such, the Veteran's noise exposure is conceded. The Veteran’s December 1981 enlistment examination included audiometric testing which documents puretone thresholds in decibels (dB), as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 0 0 0 0 0 LEFT 0 0 0 0 5 An October 1987 in-service reference audiogram documents puretone thresholds in decibels (dB) as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5 0 5 5 15 LEFT 5 0 0 10 5 The Veteran’s September 1989 separation examination documents audiometric testing with puretone thresholds in decibels (dB), as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5 5 5 10 15 LEFT 10 10 5 15 15 The Veteran was afforded a VA hearing loss and tinnitus examination in September 2014. The examiner diagnosed a current bilateral sensorineural hearing loss, but noted that electronic hearing testing conducted at enlistment, during service, and at discharge did not have a significant threshold shift beyond normal variability/normal progression while in service. Thus, based on electronic hearing testing conducted at enlistment, during service, and at discharge, the examiner opined that the Veteran’s hearing loss was less likely as not caused by or a result of noise exposure while in service. The examiner went on to provide a brief summary of references supporting the unlikeliness of delayed onset hearing loss. See September 2014 Hearing Loss and Tinnitus Disability Benefits Questionnaire. The Board finds the September 2014 VA examination inadequate. A Veteran does not have to show hearing loss at the time of discharge in order to establish service connection. In Hensley v. Brown, 5 Vet. App. 155 (1993), the United States Court of Appeals for Veterans Claims (Court) held that even though a hearing disorder may not have been demonstrated at separation, a veteran may still establish service connection for a current hearing disorder by showing he now has a hearing disorder and by submitting evidence that his current hearing disability is related to his active military service. See also Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). In Hensley, there was an upward shift in threshold levels at some frequencies on an examination for separation and in-service audiometric testing yielded elevated thresholds at some frequencies. Thus, the Court found that the claim could not be denied solely because the hearing loss did not meet the criteria for 38 C.F.R. § 3.385 at separation. Rather, if there were any current hearing loss (by VA standards) it had to be determined whether shifts in auditory thresholds during service represented the onset of any current hearing loss (even if first diagnosed a number of years after service). Thus, a claimant who seeks to establish service connection for a current hearing disability must show, as is required in a claim for service connection for any disability, that a current hearing disability is the result of an injury or disease incurred in service, the determination of which depends on a review of all the evidence of record including that pertinent to service. See 38 U.S.C. §§ 1110; C.F.R. §§ 3.303 and 3.304; Hensley, 5 Vet. App. at 159-60. Thus, in the instant case, the VA examiner essentially based the negative nexus opinion on a finding that the Veteran’s hearing at separation was within normal limits. The Board notes that the in-service puretone thresholds detailed above suggest that there were in-service threshold shifts in the Veteran’s hearing acuity. Although the VA examiner reported that the Veteran did not have a significant threshold shift beyond normal variability/normal progression while in service, the Board finds that the examiner failed to provide an adequate explanation for why the noted shifts in puretone thresholds were not significant, or could be considered of normal variability/progression. Finally, while the examiner provided references to medical literature supporting the unlikeliness of delayed onset hearing loss, he provided no indication of the onset of the Veteran’s hearing loss or a basis for why it should be considered delayed onset. Given that the Veteran had higher puretone thresholds at separation and VA regulations which consider whether a disease such as hearing loss has manifested within one year of separation from service, the omission of a discussion as to the onset and continuity of symptoms of the Veteran’s bilateral hearing loss further renders the September 2014 examination inadequate. Based on the foregoing, a remand is necessary to obtain a medical opinion with a more complete rationale regarding the etiology of the Veteran’s currently diagnosed bilateral hearing loss. Accordingly, the matter is REMANDED for the following action: 1. Obtain and associate with the claims file any pertinent records adequately identified by the Veteran, including ongoing VA medical treatment records which have not already been associated with the claims file. 2. Return the claims file to the VA examiner who provided the September 2014 Wrist Conditions DBQ and medical opinion. The claims file and a copy of this remand must be made available to the examiner. The examiner shall note in the examination report that the record and the remand have been reviewed. If the September 2014 VA examiner is not available, the record should be provided to an appropriate medical professional so as to render the requested opinion. The need for an additional examination of the Veteran is left to the discretion of the clinician selected to write the addendum opinion. After review of the record and examination, if deemed necessary, the VA examiner should offer his or her opinion as to whether the Veteran currently has a disability of the left thumb, that is separate and distinct from his already service-connected left wrist fracture. For any such disability found to be present, the examiner should express an opinion as to whether it is at least as likely as not (i.e., probability of 50 percent or greater) that such condition was incurred in, or otherwise the result of, his active service. This opinion should reflect consideration of the relevant STRs, the Veteran’s account of an in-service injury, and recurrent symptomatology since that time. A fully articulated medical rationale for each opinion expressed must be set forth in the medical report. The basis for each opinion is to be fully explained with a complete discussion of the pertinent lay and medical evidence of record and sound medical principles, including the use of any medical literature or studies, which may reasonably explain the medical analysis in the study of this case. If the examiner feels that any requested opinion cannot be rendered without resorting to speculation, the examiner should state why this is so. 3. Thereafter, obtain an addendum opinion regarding the nature and etiology of the Veteran's diagnosed bilateral hearing loss. The claims file and a copy of this remand must be made available to the reviewing examiner, and the examiner shall indicate in the addendum report that the claims file was reviewed. If an examination is deemed necessary in rendering the addendum opinion, another evaluation should be conducted. Following a review of the claims file, and if necessary an examination of the Veteran, the reviewing examiner should provide an opinion as to whether it is at least as likely as not (i.e., 50 percent probability or greater) that the Veteran's bilateral hearing loss had its onset during service or is causally or etiologically due to in-service noise exposure. The examiner must discuss the in-service audiograms of record and must discuss the shifts in hearing thresholds between the Veteran's entrance into service and his separation therefrom. For purposes of this opinion, the Board notes that there is a factual basis in the record to support the Veteran's account of his exposure to hazardous levels of noise in-service, and as such, acoustic trauma is conceded. The examiner is also advised that the Veteran is competent to report his symptoms and history, and such reports must be acknowledged and considered in formulating any opinion. A fully articulated medical rationale for each opinion expressed must be set forth in the medical report. The examiner should discuss the particulars of this Veteran's medical history and the relevant sciences as applicable to this case, which may reasonably explain the medical guidance in this study of this case. (Continued on the next page)   4. Following the completion of the foregoing, and any other development deemed necessary, the AOJ should readjudicate the Veteran's claims. If any benefit sought on appeal is denied, supply the Veteran and his representative with a supplemental statement of the case and allow an appropriate period of time for response. Thereafter, the claims folder should be returned to the Board for further appellate review, if otherwise in order. DEBORAH W. SINGLETON Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD B. Lewis