Citation Nr: 21065065 Decision Date: 10/25/21 Archive Date: 10/25/21 DOCKET NO. 16-51 770 DATE: October 25, 2021 ORDER Service connection for anemia and thalassemia is granted. Service connection for a psychiatric disorder, diagnosed as a persistent depressive disorder, with anxious distress, is granted. Service connection for left ear hearing loss is granted. REMANDED Entitlement to service connection for a liver disorder, to include non-alcoholic steatohepatitis (NASH), and an enlarged liver, is remanded. Entitlement to service connection for hypertension is remanded. Entitlement to service connection for chronic fatigue syndrome is remanded. Entitlement to service connection for a thyroid disorder, to include hypothyroidism, is remanded. Entitlement to service connection for rhinitis is remanded. Entitlement to service connection for a skin disorder is remanded. Entitlement to a compensable rating for bilateral hearing loss is remanded. Entitlement to an initial rating higher than 10 percent for residuals of a fracture of the distal left scaphoid is remanded. FINDINGS OF FACT 1. The Veteran's anemia and thalassemia had their onset in service. 2. The Veteran's psychiatric disorder, diagnosed as a persistent depressive disorder, with anxious distress, had its onset in service. 3. The Veteran's left ear hearing had its onset in service. CONCLUSIONS OF LAW 1. The criteria for service connection for anemia and thalassemia have been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1117, 1131, 1137, 1154(a), 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310, 3.317. 2. The criteria for service connection for a psychiatric disorder, diagnosed as a persistent depressive disorder, with anxious distress, have been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1117, 1131, 1137, 1154(a), 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310, 3.317. 3. The criteria for service connection for left ear hearing loss have been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1117, 1131, 1137, 1154(a), 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310, 3.317, 3.385. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the Navy from September 1990 to September 1994, including service in Southwest Asia. He also served on active duty in the Army from April 1997 to April 1998. This matter is before the Board of Veterans' Appeals (Board) on appeal of April 2015 and September 2015 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). The April 2015 RO decision granted service connection and a 10 percent rating for residuals of a fracture of the distal left scaphoid, effective February 10, 2014. By this decision, the RO also denied service connection for a psychiatric disorder, to include depression. As there are multiple other psychiatric diagnoses of record, the Board finds that it is more appropriate to characterize the claim broadly as one of entitlement to service connection for a psychiatric disorder, to include depression. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). The RO further denied service connection for anemia and thalassemia (listed as anemia, also claimed as thalassemia); a liver disorder, to include NASH and an enlarged liver; hypertension; chronic fatigue syndrome; a thyroid disorder, to include hypothyroidism; and for rhinitis. A September 2015 RO decision granted service connection and a noncompensable rating for right ear hearing loss, effective February 10, 2014. By this decision, the RO also denied service connection for a skin disorder and for left ear hearing loss. In January 2019, the Board remanded the issues of entitlement to service connection for a psychiatric disorder, to include depression; anemia and thalassemia (listed as chronic anemia, also claimed as thalassemia); a liver disorder, to include NASH and an enlarged liver (listed as NASH and an enlarged liver); chronic fatigue syndrome (listed as a disability manifested by chronic fatigue); hypertension; a thyroid disorder, to include hypothyroidism (listed as hypothyroidism); rhinitis (listed as allergic rhinitis); and for left ear hearing loss, as well as the issues of entitlement to an initial higher (compensable) rating for right ear hearing loss, and entitlement to an initial rating higher than 10 percent for residuals of a fracture of the distal left scaphoid. The Board observes that the United States Court of Appeals for Veterans Claims (Court) has held that a claim for a total disability rating based on individual unemployability (TDIU) is part of an increased rating claim when such claim is raised by the record. Rice v. Shinseki, 22 Vet. App. 447 (2009). In this case, the medical evidence indicates that the Veteran was working full-time since at least October 2019, and that he has not reported that any change in his current work status. Thus, the issue of entitlement to a TDIU is not currently before the Board. 1. Anemia and Thalassemia Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (table). Determinations as to service connection will be based on review of the entire evidence of record, to include all pertinent medical and lay evidence, with due consideration to VA's policy to administer the law under a broad and liberal interpretation consistent with the facts in each individual case. 38 U.S.C. § 1154(a); 38 C.F.R. § 3.303(a). Secondary service connection may be granted for a disability that is proximately due to, the result of, or aggravated by an established service-connected disability. 38 C.F.R. § 3.310; see also Allen v. Brown, 7 Vet. App. 439 (1995). The Veteran served in the Southwest Asia Theater of Operations during the Persian Gulf War, on or after August 2, 1990. Therefore, service connection may also be established under 38 U.S.C. § 1117; 38 C.F.R. § 3.317. Under those provisions, service connection may be warranted for a Persian Gulf Veteran who exhibits objective indications of a qualifying chronic disability that became manifest during active military, naval or air service in the Southwest Asia Theater of Operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2021. 38 C.F.R. § 3.317(a)(1). Under 38 C.F.R. § 3.317, compensation may be warranted on a presumptive basis for disabilities due to undiagnosed illness as well as medically unexplained chronic multisymptom illnesses. See 38 C.F.R. § 3.317 (a). This means that even if a Veteran's symptoms are attributed to a known clinical diagnosis, the presumptive provisions related to Gulf War service still apply. In particular, the term medically unexplained chronic multisymptom illness means a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, or disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. 38 C.F.R. § 3.317(a)(2)(ii). Therefore, even if a multisymptom illness has a diagnosis, consideration should still be given as to whether the disability has no known etiology, or has a known, partially understood etiology. Chronic multisymptom illnesses of partially understood etiology and pathophysiology, such as diabetes and multiple sclerosis, will not be considered medically unexplained. Id. In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and recurrence of symptoms. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (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. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d at 1377 (Fed. Cir. 2007) (holding that "[w]hether lay evidence is competent and sufficient in a particular case is a factual issue to be addressed by the Board"). The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C. § 7104(a) (West 2002). Moreover, the United States Court of Appeals for Veterans Claims (Court) has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. See Id. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See Id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). The Veteran contends that he has anemia and thalassemia that are related to service. He specifically maintains that he was treated for anemia and thalassemia during service. The Veteran further asserts that his anemia and thalassemia were caused by his NASH and an enlarged liver. He indicates that he was diagnosed with beta-thalassemia after his periods of service. The Veteran served on active duty in the Navy from September 1990 to September 1994, including service in Southwest Asia. He also served on active duty in the Army from April 1997 to April 1998. The Veteran's service treatment records indicate that he was counseled on two counts of going AWOL during his period of active duty in the Army from April 1997 to April 1998, and that he discharged was under honorable conditions. The Veteran's service treatment records, for his first period of active duty in the Navy from September 1990 to September 1994, do not show treatment for anemia and/or thalassemia. The service treatment records, for his period service in the Army from April 1997 to April 1998, show diagnoses of anemia and beta-thalassemia on one occasion. On a medical history form at the time of a March 1997 enlistment examination, the Veteran did not refer to any blood disorders, to include anemia and thalassemia. The reviewing examiner indicated that the Veteran was honorably discharged from the Navy in 1994, for non-medical reasons. An objective March 1997 enlistment examination report notes that a serology rapid plasma reagin (NRP) test was not reported. There was a notation that the Veteran's vascular system was normal. On a medical history form at the time of a March 1998 examination, the Veteran indicated that he was in good health. He did not refer to any blood disorders, to include anemia and/or thalassemia. The examiner also did not refer to any blood disorders, to include anemia and/or thalassemia. An objective March 1998 examination notes that a digital rectal examination was normal, and that the Veteran was Guac negative in March 1998. The examiner stated that the Veteran had low Hgb/Hc7-amemia and referred to beta-thalassemia, minor. The examiner advised that the Veteran take a Folate Acid tablet daily, and that no further work-up was needed. There was also a notation that his vascular system was normal. Post-service private and VA treatment records, including VA examination reports, show treatment for anemia; chronic anemia; anemia secondary to thalassemia minor; chronic anemia due to thalassemia; anemia, with a possible family history of "Mediterranean anemia"; anemia, iron or vitamin-deficient anemias, thalassemias, and myelophthisic anemia; thalassemia; thalassemia minor; and beta-thalassemia. A February 2015 VA hematologic and lymphatic conditions, including leukemia, examination report includes a notation that the Veteran's claims file was reviewed. The Veteran reported that he was diagnosed with thalassemia minor after active duty. He stated that he was receiving no treatment for his condition. The examiner reported that the Veteran's hemoglobin was noted to be low during active duty on several occasions, specifically in September 1994 and March 1998. It was noted that a March 1998 Hb A2 level confirmed a diagnosis of a beta-thalassemia trait. The examiner stated that a March 1998 blood smear was hypochromic, and that such was a genetic blood disorder. The examiner also stated that thalassemia minor was a known genetically transmitted anemia. The diagnosis was anemia, iron or vitamin-deficient anemias, thalassemias, myelophthisic anemia, etc. The examiner stated that beta-thalassemia was a disease with a clear and specific etiology and diagnosis. The examiner indicated that the Veteran's claimed condition was less likely than not incurred in, or caused by, the claimed in-service injury, event, or illness. The examiner reported that beta-thalassemia was a disease with a clear and specific etiology and diagnosis. It was noted that the Veteran had laboratory tests during active duty that were diagnostic of such condition. The examiner maintained that beta-thalassemia was a condition known to be transmitted genetically. The examiner stated that the Veteran's beta-thalassemia, therefore, occurred at conception, which was prior to active duty, but that it was, apparently, unknown prior to active duty. The examiner reported that beta-thalassemia could not be induced by any activity or environmental exposure. The examiner indicated that, therefore, the Veteran's beta-thalassemia was less likely than not related to any specific or non-specific exposure event experienced by him during service in Southwest Asia. A February 2015 Gulf War general medical examination report includes a notation that the Veteran's claims file was reviewed. The examiner did not refer to the Veteran's claimed anemia and thalassemia. The examiner indicated that there were not any diagnosed illnesses for which no etiology was established. The examiner reported that there were no additional signs and/or symptoms that may represent an undiagnosed illness or diagnosed medically unexplained chronic multisymptom illness. The examiner maintained that there also was no functional impact of additional signs or symptoms that may represent and undiagnosed illness or a diagnosed medically unexplained chronic multisymptom illness. The examiner reported that there was a normal physical evaluation, except for the included examination reports. An October 2019 VA hematologic and lymphatic conditions, including leukemia, examination report includes a notation that the Veteran's claims file was reviewed. The examiner reported that, in March 1998, the Veteran had a diagnosis of chronic anemia/thalassemia based on laboratory findings, a hemoglobin A2 fraction. The examiner stated that such was an inherited disease that was present since conception. The examiner indicated that routing blood work, while the Veteran was in the service, noticed mild anemia, and that further testing revealed that he had a genetic blood disorder named beta-thalassemia or thalassemia minor. It was noted that the cause of the Veteran's condition was genetic/inherited and that the progress of the condition, since onset, had been the same. The examiner related that the Veteran's current symptom was fatigue, and that he underwent periodic blood testing to monitor the degree of his anemia. The diagnoses were anemia and beta-thalassemia. The examiner indicated that the claimed conditions were less likely than not (less than 50 percent probability) incurred in, or caused by, the claimed in-service injury, event, or illness. The examiner stated that thalassemia minor was diagnosed during service, but that it was a genetic disease, which meant that the Veteran had it since conception. In an August 2020 addendum opinion, the same examiner reported that the Veteran's thalassemia clearly and unmistakably did not manifest prior to the Veteran's active service because thalassemia was a genetic disorder affecting the blood that was present since birth and could not be aggravated, and there was no aggravation to be considered. The examiner stated that the Veteran's thalassemia clearly and unmistakably pre-existed the Veteran's active service and that it was clearly and unmistakably not aggravated during his active service because thalassemia was an inherited blood disorder that could not be aggravated. The Board observes that the Veteran's service treatment records, for his first period of active duty in the Navy from September 1990 to September 1994, do not show treatment for anemia and/or thalassemia. The Board notes, however, that the Veteran's service treatment records, for his period of active duty in the Army from April 1997 to April 1998, show diagnoses of anemia and beta-thalassemia. An objective March 1998 examination notes that the Veteran had low Hgb/Hc7-amemia and referred to beta-thalassemia, minor. The examiner advised that the Veteran take a Folate Acid tablet daily, and that no further work-up was needed. The Board observes that post-service treatment records show treatment for anemia; chronic anemia; anemia secondary to thalassemia minor; chronic anemia due to thalassemia; anemia, with a possible family history of "Mediterranean anemia"; anemia, iron or vitamin-deficient anemias, thalassemias, and myelophthisic anemia; thalassemia; thalassemia minor; and beta-thalassemia. The Board observes that a February 2015 VA hematologic and lymphatic conditions, including leukemia, examination report relates a diagnosis of anemia, iron or vitamin-deficient anemias, thalassemias, myelophthisic anemia, etc. The examiner, following a review of the claims file, stated that beta-thalassemia was a disease with a clear and specific etiology and diagnosis. The examiner also indicated that the Veteran's claimed condition was less likely than not incurred in, or caused by, the claimed in-service injury, event, or illness. The examiner reported that beta-thalassemia was a disease with a clear and specific etiology and diagnosis, and that the Veteran had laboratory tests during active duty that were diagnostic of such condition. The examiner opined that beta-thalassemia was a condition known to be transmitted genetically. The examiner stated that the Veteran's beta-thalassemia, therefore, occurred at conception, which was prior to active duty, but that it was, apparently, unknown prior to active duty. The examiner reported that beta-thalassemia could not be induced by any activity or environmental exposure. The examiner indicated that, therefore, the Veteran's beta-thalassemia was less likely than not related to any specific or non-specific exposure event experienced by him during service in Southwest Asia. The Board observes that the examiner found that the Veteran's beta-thalassemia was not incurred in, or caused by, his claimed in-service injury, event, or illness. The examiner also stated that the beta-thalassemia was a condition known to be transmitted genetically, that it occurred at conception, which was prior to active duty, and that it could not be induced by any activity or environmental exposure. The Board notes that the examiner did not specifically address the multiple diagnoses of anemia subsequent to service. The Board also observes that the examiner did not specifically address the evidence that the Veteran was not diagnosed with anemia and/or thalassemia during his first period of service in the Navy, from September 1990 to 1994, that he was not diagnosed with such conditions at the time of his enlistment examination in the Army in March 1997, and that he was not diagnosed with such conditions until March 1998. Therefore, the Board finds that the examiner's opinions, pursuant to the February 2015 VA hematologic and lymphatic conditions, including leukemia, examination report, are less probative in this matter. The Board notes that a February 2015 VA Gulf War general medical examination report, notes that there were not any diagnosed illnesses for which no etiology was established. The examiner also reported that there were no additional signs and/or symptoms that may represent an undiagnosed illness or diagnosed medically unexplained chronic multisymptom illness. The examiner further maintained that there also was no functional impact of additional signs or symptoms that may represent and undiagnosed illness or a diagnosed medically unexplained chronic multisymptom illness. The Board observes that the examiner did not specifically address the Veteran's claimed anemia and thalassemia. In fact, the examiner reported that there was a normal physical evaluation, except for included examinations. The Board finds that the February 2015 VA Gulf War general medical examination report has little probative value in this matter. The Board notes that an October 2019 VA hematologic and lymphatic conditions, including leukemia, examination report relates diagnoses of anemia and beta-thalassemia. The examiner indicated that the claimed conditions were less likely than not incurred in, or caused by, the claimed in-service injury, event, or illness. The examiner stated that thalassemia minor was diagnosed during service, but that it was a genetic disease, which meant that the Veteran had it since conception. In an August 2020 addendum, the same examiner maintained that the Veteran's thalassemia clearly and unmistakably did not manifest prior to his active service because thalassemia was a genetic disorder affecting the blood that was present since birth and could not be aggravated, and there was no aggravation to be considered. The examiner stated that the Veteran's thalassemia clearly and unmistakably pre-existed the Veteran's active service and that it was clearly and unmistakably not aggravated during his active service because thalassemia was an inherited blood disorder that could not be aggravated. The Board observes that the examiner diagnosed anemia and beta-thalassemia, but essentially, only addressed the Veteran's thalassemia. The examiner did not address the numerous diagnoses of anemia since the Veteran's periods of service. Additionally, the notes that the examiner did not address the evidence that the Veteran was not diagnosed with anemia and/or thalassemia during his first period of service in the Navy, from September 1990 to 1994, that he was not diagnosed with such conditions at the time of his enlistment examination in the Army in March 1997, and that he was not diagnosed with such conditions until March 1998. The Board also notes that the examiner found that the Veteran's thalassemia clearly and unmistakably pre-existed to his active service and that it was clearly and unmistakably not aggravated during his active service because thalassemia was an inherited blood disorder that could not be aggravated. The Board observes, however, that service connection may be granted for congenital diseases, but not congenital defects. Quirin v. Shinseki, 22 Vet. App. 390, 394 (2009) (discussing VAOPGCPREC 82-90); Monroe v. Brown, 4 Vet. App. 513, 515 (1993). When no pre-existing medical condition is noted upon entry into service, a Veteran is presumed to have been sound upon entry. 38 U.S.C.A. § 1111 (West 2002); Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004); Bagby v. Derwinski, 1 Vet. App. 225, 227 (1991). The presumption of soundness applies if a veteran's congenital disease is not noted at entry. See Quirin, 22 Vet. App. at 396-97, Monroe, 4 Vet. App. at 515. The burden then falls on the Government to rebut the presumption of soundness by clear and unmistakable evidence that the disability was both preexisting and not aggravated by service. Wagner, 370 F.3d at 1096; Bagby, 1 Vet. App. at 227. Accordingly, [o]nce the presumption of soundness applies, the burden of proof remains with the Secretary on both the preexistence and the aggravation prong; it never shifts back to the claimant. In particular, even when there is clear and unmistakable evidence of preexistence, the claimant need not produce any evidence of aggravation in order to prevail under the aggravation prong of the presumption of soundness... the burden is not on the claimant to show that his disability increased in severity; rather, it is on VA to establish by clear and unmistakable evidence that it did not or that any increase was due to the natural progress of the disease. Horn v. Shinseki, 25 Vet. App. 231, 235 (2012) (emphasis added). This burden must be met by "affirmative evidence" demonstrating that there was no aggravation. See id. The burden is not met by finding "that the record contains insufficient evidence of aggravation." See id. Here, the Veteran was not diagnosed with anemia and thalassemia during his first period of active duty in the Navy from September 1990 to September 1994. Additionally, he was not diagnosed with anemia and thalassemia at the time of his March 1997 enlistment examination, for his period of active duty. In fact, he was diagnosed with anemia and thalassemia in March 1998, prior to his discharge from the Army in April 1998. Thus, he must be presumed sound upon entry during both periods of active duty, to specifically include his period of active duty in the Army. As noted above, the presumption of soundness applies if a veteran's congenital disease is not noted at entry. See Quirin, 22 Vet. App. at 396-97, Monroe, 4 Vet. App. at 515. As such, the Veteran was presumed sound at the time of his entry into the Army in April 1997, he was diagnosed with anemia and thalassemia during his period of active duty in the Army from April 1997 to April 1998, and he is currently diagnosed with anemia and thalassemia. See 38 C.F.R. § 3.303(a). Resolving any doubt in the Veteran's favor, the Board finds that the evidence is at least in equipoise as to whether his anemia and thalassemia commenced during his period of service. In light of the evidence, the Board cannot conclude that the preponderance of the evidence is against granting service connection for anemia and thalassemia. Thus, service connection for anemia and thalassemia is warranted. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. As the Board has granted direct service connection, it need not address other theories of service connection. 2. Psychiatric Disorder, to include Depression Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a) (i.e., under the criteria of DSM-IV); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. If the evidence establishes that the veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304(f). Further, 38 C.F.R. § 3.304(f) provides that if a stressor claimed by a Veteran is related to the Veteran's fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of [PTSD] and that the Veteran's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the Veteran's service, the Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. The Veteran is service-connected for residuals of a fracture of the distal left scaphoid; right ear hearing loss; and for tinnitus. As discussed above, the Veteran is now also service-connected for anemia and thalassemia. The Veteran contends that he is a psychiatric disorder, to include depression, that is related to service. He specifically maintains that he received treatment and group therapy for depression during his period of active duty in the Army from April 1997 to April 1998, and that he has continued to receive such treatment to the present. He states that he went AWOL during his period of active duty in the Army. The Veteran also reports that worrying about his claimed service-connected conditions also caused his depression. He further states that his depression began during his period of active duty in the Navy from September 1990 to 1994. The Veteran essentially asserts that his psychiatric disorder, to depression, began during his periods of service, and that it has continued since that time. The Veteran served on active duty in the Navy from September 1990 to September 1994, including service in Southwest Asia. He also served on active duty in the Army from April 1997 to April 1998. The Veteran's service treatment records indicate that he was counseled on two counts of going AWOL during his period of active duty in the Army from April 1997 to April 1998, and that he discharged was under honorable conditions. The service treatment records, for his first period of active duty in the Navy from September 1990 to September 1994, do not show treatment for any psychiatric problems. The Veteran's service treatment records, for his period of active duty in the Army from April 1997 to April 1998, also do not specifically show treatment for psychiatric problems. Such records do show that the Veteran underwent a mental status evaluation on one occasion. A March 1998 mental status evaluation report notes that the Veteran was seen based on a command referral for a mental status evaluation. The examiner reported that the Veteran's behavior was normal, and that he was fully alert and fully oriented. It was noted that the Veteran's mood or affect was unremarkable, that his thinking process was clear. The examiner indicted that the Veteran's thought content was normal, and that his memory was good. The examiner maintained that the Veteran was mentally responsible, and that he had the mental capacity to participate in proceedings. The examiner stated that there was no mental disorder that would warrant disposition through medical channels. The examiner reported that the Veteran was cleared for any administrative action deemed appropriate by his command. Post-service private and VA treatment records, including VA examination reports, show treatment for variously diagnosed psychiatric disorders, including a generalized anxiety disorder; rule out dysthymia; a mood disorder; depression; a depressive disorder; a depressive disorder, unspecified; a major depressive disorder; a persistent depressive disorder; and a persistent depressive disorder, with anxious features. A March 2015 VA psychiatric examination report includes a notation that the Veteran's claims file was reviewed. The Veteran reported that he had no legal problems or disciplinary problems while serving in the Navy. He stated that he went AWOL in the Army to initiate a discharge. The Veteran indicated that he had no health problems prior to service, and that he had problems with his wrist, knees, and back, during service. He stated that, after his military service, he had temper control difficulties, but that he had not received mental health treatment. The diagnosis was a persistent depressive disorder. The examiner indicated that the claimed condition was less likely than not (less than 50 percent probability) incurred in, or caused by, the claimed in-service injury, event, or illness. The examine reported that the Veteran was diagnosed with a persistent depressive disorder (a.k.a. dysthymia). The examiner stated that the Veteran was diagnosed with depression of a mild range of severity (dysthymic) based upon VA treatment reports in May 2002 and June 2002. The examiner maintained that the etiology of the Veteran's depression in 2002 was evidenced by life stressors of a divorce, his parent's illness, and financial and occupational stressors. It was noted that there was no mental health treatment session from August 2002 to March 2015. An October 2019 VA psychiatric examination report includes a notation that the Veteran's claims file was reviewed. The Veteran reported that he served in the Navy from 1990 to 1994. He stated that he was then in the Reserves, and that he went into the Army from 1997 to 1998. He maintained that he received a general under honorable conditions discharge because he went AWOL. The Veteran indicated that, at that time, he wasn't getting along with his wife, his mother was sick, and that he had just had it. The Veteran reported that he saw a counselor at Fort Gordon in Georgia in 1998. He stated that he was required to go to counseling for depression because he had gone AWOL. He related that he attended counseling for three months. The diagnosis was a persistent depressive disorder, with anxious distress. The examiner reported that the Veteran became depressed in the military and that he went AWOL twice. The examiner stated that the Veteran had continued to experience depression since that time, and that he had taken medication for the pervious five years. The examiner indicated that the claimed condition was at least as likely as not (50 percent or greater probability) incurred in, or caused by, the claimed in-service injury, event, or illness. The examiner maintained that the Veteran's medical records support that his currently diagnosed persistent depressive disorder/depression was at least as likely as not (50 percent or greater probability) incurred in, or caused by, his depression during service. The examiner reported that the Veteran saw a counselor at Fort Gordon in Georgia in 1998, and that he was required to go to counseling for depression because he went AWOL. It was noted that the Veteran attended the counseling for three months. The examiner stated that the Veteran received counseling at a VA facility about five years ago, and that he went for about a year, but discontinued treatment because he did not get along well with the counselor. The examiner related that the Veteran saw another counselor a few times, but that he discontinued treatment because he did not have time. It was noted that the Veteran's current primary care physician prescribed Cymbalta twice per day, and that the Veteran had been taking such medication for five years. The examiner maintained that the Veteran had never received psychiatric treatment, and that he did not go to an emergency room for the assessment and treatment of mental health conditions. The examiner indicated that the Veteran's depression had continued since he was in the military. In September 2020, the RO requested an additional opinion from the examiner who performed the October 2019 VA psychiatric examination report. The RO indicated that the examiner did not provide the opinions requested by the Board in a January 2019 Board remand. The RO also notified the examiner that there was some additional information. The RO stated that a November 2015 treatment note documents that, in retrospect, the Veteran identified the three-year time period, between his service in the Navy and the Army, as the beginning of his first experiences of depression. The RO reported that the treatment note shows that the Veteran had multiple stressors, at that time, including a dysfunctional marriage, having to file for bankruptcy with accompanying financial distress, and the death of his mother. The RO related that the treatment note also documents that the Veteran had left the Navy to find that his wife of seven years had driven them into bankruptcy and had been involved in infidelities. It was noted that the Veteran divorced his wife, and that he then lost his mother to illness a year later. The RO indicated that the Veteran reported, at that time, that he was close to his mother, that he still actively mourned her death ten years later, and that because of financial issues, he signed up with the Army in 1997, but hated it. The RO noted that the Veteran stated that he wrote to congressman asking to be released, and that he finally went AWOL twice before negotiating a general honorable discharge a year later. The examiner indicated that such treatment note shows that stressors, and mourning the loss of his mother, were still impacting the Veteran when he joined the Army, and he went AWOL. The examiner reported that the Veteran served in the Navy, but that he did not go AWOL from the Navy when the stressors were not present. It was noted that a prescription for Duloxetine HCL, for depression, was dated in April 2002. The examiner maintained that, therefore, it was less likely than not that the Veteran's psychiatric disorder was incurred in, or caused by, his military service. The Board observes that the Veteran's service treatment records, for his first period of active duty in the Navy from September 1990 to September 1994, do not show treatment for any psychiatric problems. The Board also notes that the Veteran's service treatment records, for his period of active duty in the Army from April 1997 to April 1998, also do not specifically show treatment for psychiatric problems, but that such records do show that he underwent a mental status evaluation on one occasion. A March 1998 mental status evaluation report notes that the Veteran was seen based on a command referral for a mental status evaluation. The examiner maintained that the Veteran was mentally responsible, and that he had the mental capacity to participate in proceedings. The examiner also stated that there was no mental disorder that would warrant disposition through medical channels, and that the Veteran was cleared for any administrative action deemed appropriate by his command. The Board notes that post-service treatment records show treatment for variously diagnosed psychiatric disorders, including a generalized anxiety disorder; rule out dysthymia; a mood disorder; depression; a depressive disorder; a depressive disorder, unspecified; a major depressive disorder; a persistent depressive disorder; and a persistent depressive disorder, with anxious features. The Board observes that a March 2015 VA psychiatric examination report relates a diagnosis of a persistent depressive disorder. The examiner, following a review of the claims file, indicated that the claimed condition was less likely than not incurred in, or caused by, the claimed in-service injury, event, or illness. The examiner reported that the Veteran was diagnosed with a persistent depressive disorder (a.k.a. dysthymia) based upon VA treatment reports in May 2002 and June 2002. The examiner maintained that the etiology of the Veteran's depression in 2002 was evidenced by life stressors of a divorce, his parent's illness, and financial and occupational stressors. It was noted that there was no mental health treatment session from August 2002 to March 2015. The Board observes that the examiner did not provide much in the way of a rationale for the opinion that the Veteran's diagnosed persistent depressive disorder was not related to his period of service. Additionally, the examiner did not address the Veteran's reports of psychiatric problems during service and since service. The Veteran is competent to report psychiatric problems during service and since service. See Davidson, 581 F.3d 1313 (Fed. Cir. 2009). Therefore, the Board finds that the examiner's opinions, pursuant to the March 2015 VA psychiatric examination report, are not very probative in this matter. The Board observes an October 2019 VA psychiatric examination report relates a diagnosis of a persistent depressive disorder, with anxious distress. The examiner, following a review of the claims file, reported that the Veteran became depressed in the military and that he went AWOL twice. The examiner stated that the Veteran had continued to experience depression since that time, and that he had taken medication for the previous five years. The examiner indicated that the claimed condition was at least as likely as not incurred in, or caused by, the claimed in-service injury, event, or illness. The examiner specifically maintained that the Veteran's medical records support that his currently diagnosed persistent depressive disorder/depression was at least as likely as not incurred in, or caused by, his depression during service. The Board notes, however, that, in September 2020, the RO requested an additional opinion from the examiner and provided additional information and referred in detail to a November 2015 treatment note. The examiner then concluded, based, apparently, on that November 2015 treatment note, that it was less likely than not that the Veteran's psychiatric disorder was incurred in, or caused by, his military service. After a review of the evidence of record, the Board finds the additional medical opinion solicited by the RO, in September 2020, regarding the etiology of the Veteran's claimed psychiatric disorder, to include depression, was improper. In the request for an opinion, the RO specifically stated that there was some additional information, and that a November 2015 note documents that, in retrospect, the Veteran identified the three-year time period between his service in the Navy and the Army as the beginning of his first experiences of depression. The language of the RO's request for an opinion suggested, and in effect, requested, that the addendum opinion refute the earlier October 2019 opinion that the Veteran's diagnosed persistent depressive disorder, with anxious distress, was related to his period of service. The Board finds that the September 2020 addendum medical opinion was obtained by a tainted process where the solicitation from the RO that led to the medical opinion contained information that suggested an answer and limited the field of inquiry. See Colayong v. West, 12 Vet. App. 524, 534-35 (1999); see also Sizemore v. Principi, 18 Vet. App. 264, 275-76 (2004); Bielby v. Brown, 7 Vet. App. 260, 268-69 (1994); Austin v. Brown, 6 Vet. App. 547, 552 (1994). Accordingly, the Board finds the September 2020 addendum medical opinion is "tainted" and thus may not be considered in the adjudication of this issue. See Colayong v. West, 12 Vet. App. at 536. As a result of the impropriety leading to the September 2020 addendum opinion, and the lack of probative value of the opinion due to such impropriety, the only probative medical opinion remaining is that of the October 2019 VA psychiatric examination report, which found that the Veteran's diagnosed persistent depressive disorder, with anxious distress, was related to his period of service (specifically his period of active duty in the Army from April 1997 to April 1998). Resolving any doubt in the Veteran's favor, the Board finds that the evidence is at least in equipoise regarding whether the current psychiatric disorder, diagnosed as a persistent depressive disorder, with anxious distress, commenced during his period of service (specifically his period of active duty in the Army from April 1997 to April 1998). In light of the evidence of record, the Board cannot conclude that the preponderance of the evidence is against granting service connection for a psychiatric disorder, diagnosed as a persistent depressive disorder, with anxious distress. Accordingly, service connection for a psychiatric disorder, diagnosed as a persistent depressive disorder, with anxious distress, is warranted. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; see also Clemons v. Shinseki, 23 Vet. App. 1 (2009). As the Board has granted service connection for a psychiatric disorder, diagnosed as a persistent depressive disorder, with anxious distress, on a direct basis, it need not address any other theories of service connection. 3. Left Ear Hearing Loss Impaired hearing will be considered to be a disability for VA purposes when the thresholds for any of the frequencies of 500, 1000, 2000, 3000, and 4000 Hertz are 40 decibels or more; the thresholds for at least three of these frequencies are 26 decibels; or speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. One requirement for service connection is the current existence of the claimed disability. With regard to hearing loss, 38 C.F.R. § 3.385 defines what constitutes the current existence of a hearing loss disability. For service connection, it is not required that a hearing loss disability by the standards of 38 C.F.R. § 3.385 be demonstrated during service, although a hearing loss disability by the standards of 38 C.F.R. § 3.385 must be currently present, and service connection is possible if such current hearing loss disability can be adequately linked to service. Ledford v. Derwinski, 3 Vet. App. 87 (1992). The Veteran is service-connected for right ear hearing loss and for tinnitus. He is also service-connected for residuals of a fracture of the distal left scaphoid. As discussed above, the Veteran is now further service-connected for anemia and thalassemia, and for a psychiatric disorder, diagnosed as a persistent depressive disorder, with anxious distress. The Veteran contends that he has left ear hearing loss that is related to service. He specifically maintains that he has left ear hearing loss as a result of acoustic trauma that he experienced during his active duty in the Navy, from September 1990 to September 1994, as an operator in the engine rooms on the USS Orion and USS Spartanburg. The Veteran also maintains that he was exposed to noise from M-16 rifles while serving on active duty in the Army from April 1997 to April 1998. He further reports that he has long-term tinnitus that possibly began during his military service. The Veteran served on active duty in the Navy from September 1990 to September 1994, including service in Southwest Asia. He also served on active duty in the Army from April 1997 to April 1998. The Veteran's service treatment records indicate that he was counseled on two counts of going AWOL during his period of active duty in the Army from April 1997 to April 1998, and that he discharged was under honorable conditions. The Veteran's service treatment records, for his period of active duty in the Navy from September 1990 to September 1994, do not specifically show a hearing loss disability in the left ear as defined by 38 C.F.R. § 3.385. There is also no specific evidence of left hearing loss within the year after the Veteran's period of active duty as required for the presumption of service connection. His service treatment records, for his period of active duty in the Army from April 1997 to April 1998, also do not show a hearing loss disability in the left ear as defined by 38 C.F.R. § 3.385. There is no specific evidence of left hearing loss within the year after the Veteran's period of active duty as required for the presumption of service connection. Post-service private and VA treatment records, including a VA examination report, show treatment for left ear hearing loss. The evidence of record shows that the Veteran was exposed to in-service acoustic trauma and that he has been currently diagnosed with left ear hearing loss, under the provisions of 38 C.F.R. § 3.385. A September 2015 VA audiological examination report includes a notation that the Veteran's claims file was reviewed. The Veteran reported that he had noise exposure, with an occupational specialty as an engineman. He stated that he used hearing protection for occupational and recreational noise exposure following his military service. The examiner reported results that were indicative of left ear hearing loss as defined by 38 C.F.R. § 3.385. The diagnoses included sensorineural hearing loss, in the frequency range of 500 to 4000 Hertz, and in the frequency range of 6000 Hertz or higher frequencies, in the left ear. The examiner indicated that the Veteran's left ear hearing loss was not at least as likely as not (50 percent probability or greater) caused by, or a result of, an event during military service. The examiner reported that based on audiometric examinations that show no significant change in hearing thresholds from enlistment to separation during military service in the left ear, hearing loss in the left ear during the Veteran's military service was ruled out. Subsequent VA treatment records indicate that the Veteran was diagnosed with bilateral sensorineural hearing loss on multiple occasions. An October 2019 VA audiological examination report includes a notation that the Veteran's claims file was reviewed. The Veteran reported that he worked in the engine and boiler rooms of ships while serving in the Navy, which were very loud. He stated that he was around the firing of weapons while serving in the Army. The Veteran indicated that following his military service, he worked in a power plant, where he was required to wear hearing protection only if he was around areas that were noisy, and that such was typically no more than twenty to thirty-nine minutes per day. The examiner reported results that were not indicative of left ear hearing loss as defined by 38 C.F.R. § 3.385. The diagnoses included normal hearing in the left ear. The examiner indicated that the Veteran's hearing in his left ear was normal, and that, therefore, it was less likely than not that his left ear hearing loss was caused by his military service. In a September 2020 addendum, the examiner indicated that the Veteran's left ear hearing loss was not at least as likely as not (50 percent probability or greater) caused by, or a result of, an event during military service. The examiner reported that she could not account for the validity of a VA audiological examination report in September 2015 as she did not test the Veteran on that date. The examiner stated that the Veteran was tested in October 2019 and that the left ear showed normal hearing at all the frequencies tested. The examiner maintained that the difference in thresholds at 3000 and 4000 Hertz between the October 2019 audiological examination report and the September 2015 audiological examination report are significant beyond test/retest reliability. The examiner stated that the results obtained in October 2019 were normal and she did not believe the Veteran's left ear hearing loss was caused by miliary noise exposure. The examiner reported that the Veteran's service treatment records show no sign of treatment for hearing loss or shifts in the Veteran's hearing in the left ear during service. It was noted that the Veteran did work around some hazardous noise after his separation from service. The examiner indicated that the testing does not show a hearing loss in the left ear and that such is clear evidence and hard data. The Board observes that the evidence shows that the Veteran was exposed to in-service acoustic trauma and that he has left ear hearing loss for VA compensation purposes. The Boards notes that a September 2015 VA audiological examination report indicates results that were indicative of left ear hearing loss as defined by 38 C.F.R. § 3.385, and relates diagnoses that included sensorineural hearing loss, in the frequency range of 500 to 4000 Hertz, and in the frequency range of 6000 Hertz or higher frequencies, in the left ear. The examiner, following a review of the claims file, indicated that the Veteran's left ear hearing loss was not at least as likely as not caused by, or a result of, an event during military service. The examiner reported that based on audiometric examinations that show no significant change in hearing thresholds from enlistment to separation during military service in the left ear, hearing loss in the left ear during the Veteran's military service was ruled out. The Board observes that the examiner appears to indicate that because there was no significant change in hearing thresholds during service, hearing loss in the left ear during the Veteran's periods of service was ruled out. The Board notes, however, that in regard to the Veteran's left ear hearing loss, the absence of documented hearing loss, as defined by VA, while in service is not fatal to a claim for service connection. See Ledford, 3 Vet. App. at 87. Additionally, when a Veteran does not meet the regulatory requirements for a disability at separation, he can still establish service connection by submitting evidence that a current disability is causally related to service. Hensley v. Brown, 5 Vet. App. 155, 159-160 (1993). The Board further notes that the examiner did not address the Veteran's report that he may have had tinnitus during service, or any reports of left ear hearing loss during and since service. The Veteran is competent to report in-service left ear hearing problems, continuous left ear hearing loss symptomatology since service, and current symptoms that form the basis for diagnosis of disability. See Davidson, 581 F.3d at 1313. Therefore, the Board finds that the VA examiner's opinions, pursuant to the September 2015 VA audiological examination report, are not probative in this matter. The Board notes that an October 2019 VA audiological examination report indicates results that were not indicative of left ear hearing loss as defined by 38 C.F.R. § 3.385, and relates diagnoses that included normal hearing in the left ear. The examiner, following a review of the claims file, indicated that the Veteran's hearing in his left ear was normal, and that, therefore, it was less likely than not that his left ear hearing loss was caused by his military service. Additionally, in a September 2020 addendum, the examiner indicated that the Veteran's left ear hearing loss was not at least as likely as not caused by, or a result of, an event during military service. The examiner reported that she could not account for the validity of a VA audiological examination report in September 2015 as she did not test the Veteran on that date. The examiner stated that the Veteran was tested in October 2019 and that the left ear showed normal hearing at all the frequencies tested. The examiner maintained that the results obtained in October 2019 were normal and she did not believe the Veteran's left ear hearing loss was caused by miliary noise exposure. The Board observes that that findings of left ear hearing loss, pursuant to the September 2015 VA audiological examination report, and normal hearing in the left ear, pursuant to the October 2019 VA audiological examination report, and the September 2020 addendum, clearly provide conflicting evidence. The Board notes that the examiner, pursuant to the October 2019 VA audiological examination report, and the September 2020 addendum, did not address the numerous recent VA treatment records showing diagnoses of bilateral sensorineural hearing loss. The Board observes that the evidence more clearly shows that the Veteran has left ear hearing loss, pursuant to 38 C.F.R. § 3.385. Therefore, the Board finds that the opinions and findings by the examiner, pursuant to the October 2019 VA audiological examination report, are less probative in this matter. The Veteran is competent to report left ear hearing problems during service and since that time. Moreover, the Board finds that his reports of noise exposure during service, possible hearing problems during service such as tinnitus, as well as hearing problems since service, to be credible. See also Jandreau v. Nicholson, 492 F.3d 1372 (2007). The Board notes that the Veteran is already service-connected for right ear hearing loss and for tinnitus based on acoustic trauma during his periods of service. Resolving all reasonable doubt in his favor, the Board finds that the Veteran has left ear hearing loss that had its onset during his periods of service. As such, service connection is warranted. As the Board has granted direct service connection in this matter, it need not address other theories of service connection. REASONS FOR REMAND The remaining issues on appeal are entitlement to service connection for a liver disorder, to include NASH, and an enlarged liver; hypertension; chronic fatigue syndrome; a thyroid disorder, to include hypothyroidism; rhinitis; and a skin disorder, as well as entitlement to an initial higher (compensable) rating for bilateral hearing loss, and entitlement to an initial rating higher than 10 percent for residuals of a fracture of the distal left scaphoid. As discussed above, the Board has granted service connection for left ear hearing loss. Given this change in circumstances, and to accord the Veteran due process, the RO must now readjudicate the issue of entitlement to an initial higher (compensable) rating for bilateral hearing loss. See 38 C.F.R. 4.85, 4.86, Diagnostic Code 6100. The Board has also granted service connection for anemia and thalassemia, and for a psychiatric disorder, diagnosed as a persistent depressive disorder, with anxious distress. Given this change in circumstances, and to accord the Veteran due process, the RO should also readjudicate the issues of entitlement to service connection for a liver disorder, to include NASH, and an enlarged liver; hypertension; chronic fatigue syndrome; a thyroid disorder, to include hypothyroidism; rhinitis; and for a skin disorder. Additionally, this case was last remanded in January 2019, partly to schedule the Veteran for VA examinations regarding his claims for service connection for hypertension; chronic fatigue syndrome; rhinitis; and for a skin disorder. Then, based on the results of the examinations, the examiner(s) was/were to address a number of questions. Pursuant to the January 2019 Board remand, the Veteran was afforded a VA hypertension examination in October 2019. He was also afforded a VA chronic fatigue syndrome examination in October 2019. The Veteran was further afforded a VA sinusitis, rhinitis, and other conditions of the nose, throat, and larynx and pharynx, examination in October 2019, as well as a VA skin diseases examination in October 2019. The Board notes that the RO also afforded the Veteran a VA hepatitis, cirrhosis, and other liver conditions, examination in October 2019. The Board notes that there were also addendum opinions provided in September 2020. The Board finds that those examinations are inadequate. For example, the examinations do not properly address the claimed disorders, pursuant to the provisions of 38 C.F.R. § 3.317. Additionally, the Board notes that subsequent to the above examination reports, to include the September 2020 addendum opinions, the Board granted service connection for anemia and thalassemia, and for a psychiatric disorder, diagnosed as a persistent depressive disorder, with anxious distress. The examiner was not able to address whether the Veteran's claimed liver disorder, to include NASH, and an enlarged liver; hypertension; chronic fatigue syndrome; rhinitis; and skin disorder, were caused or aggravated by his now service-connected anemia and thalassemia, and for a psychiatric disorder, diagnosed as a persistent depressive disorder. In El-Amin v. Shinseki, 26 Vet. App. 136 (2013), a decision issued by the United States Court of Appeals for Veterans Claims (Court), the Court vacated a decision of the Board where a VA examiner did not specifically opine as to whether a disability was aggravated by a service-connected disability. Additionally, the examiner, pursuant to the VA sinusitis, rhinitis, and other conditions of the nose, throat, and larynx and pharynx, examination, report, stated that there was no apparent treatment for rhinitis during the Veteran's periods of service. The Board notes, however, that the Veteran was treated for upper respiratory symptoms on multiple occasions during his periods of service. The Board observes that the examiner, pursuant to the October 2019 VA skin diseases examination report, found that the Veteran did not have any current skin diseases. The Board notes, however, that multiple private and VA treatment records show that the Veteran was treated for skin problems, including an atypical mole, a MRSA infection, cellulitis and tiny abscesses, etc. The Board further notes that the Veteran has not been afforded a VA examination, as to his claim for service connection for a thyroid disorder, to include hypothyroidism. In light of the above, the Board finds that the Veteran should be afforded a VA examination with the opportunity to obtain responsive etiological opinions, following a thorough review of the record, as to his claims for service connection for a liver disorder, to include NASH, and an enlarged liver; hypertension; chronic fatigue syndrome; a thyroid disorder, to include hypothyroidism; rhinitis; and for a skin disorder. Such an examination must be accomplished on remand. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006); Stefl v. Nicholson, 21 Vet. App. 120, 125 (2007); see also Stegall v. West, 11 Vet. App. 268, 271 (1998). Additionally, as to the Veteran's claim for a higher rating for his bilateral hearing loss, the Board notes that the Veteran was last afforded a VA audiological examination in October 2019. Since that time, as noted above, the Board has granted service connection for left ear hearing loss. Additionally, the October 2019 VA audiological examination report found normal hearing in the Veteran's left ear. The Board notes that the Veteran has not been afforded a VA examination, as to his service-connected bilateral hearing loss, in approximately two years, and that the record clearly raises a question as to the current severity of that service-connected disability. See Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). As such, the Board finds it necessary to remand this matter to afford the Veteran an opportunity to undergo a contemporaneous VA examination. Finally, the Board notes that, as to the Veteran's claim for a higher rating for his service-connected residuals of a fracture of the distal left scaphoid, the Veteran was last afforded a VA wrist conditions examination in February 2015. The diagnosis was a personal history of a fracture of the distal left scaphoid, healed. Since that time, in a statement in October 2016, the Veteran's representative indicated that the Veteran had received significant treatment for his service-connected residuals of a fracture of the distal left scaphoid, to include secondary neuropathy. The Board notes that the U.S Court of Appeals for Veteran's Claims (Court) has issued a decision in Sharp v. Shulkin, 29 Vet. App. 26 (2017) concerning the adequacy of VA examinations. The Court in Sharp held that before a VA examiner opines that he or she cannot offer an opinion as to additional functional loss during flare-ups without resorting to speculation based on the fact that the examination was not performed during a flare, the examiner must "elicit relevant information as to the veteran's flares or ask him to describe the additional functional loss, if any, he suffered during flares and then estimate the veteran's functional loss due to flares based on all the evidence of record, including the veteran's lay information, or explain why she could not do so." In light of this decision, and as the findings, pursuant to the February 2015 VA wrist conditions examination report, are inadequate, the Board finds that new a VA examination should be provided addressing the Veteran's service-connected residuals of a fracture of the distal left scaphoid. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) see also Snuffer, 10 Vet. App. at 400, 403. The matters are REMANDED for the following action: 1. Ask the Veteran to identify all medical providers who have treated him for a liver disorder, to include NASH, and an enlarged liver; hypertension; chronic fatigue syndrome; a thyroid disorder, to include hypothyroidism; rhinitis; a skin disorder; bilateral hearing loss; and for residuals of a fracture of the distal left scaphoid, since September 2020. After receiving this information and any necessary releases, obtain copies of the related medical records which are not already in the claims folder. Document any unsuccessful efforts to obtain the records, inform the Veteran of such, and advise him that he may obtain and submit those records himself. 2. Notify the Veteran that he may submit lay statements from himself and from other individuals who have first-hand knowledge, and/or were contemporaneously informed of his in-service and post-service symptoms of liver disorder, to include Nash, and an enlarged liver; hypertension; chronic fatigue syndrome; thyroid disorder, to include hypothyroidism; rhinitis; and skin disorder, as well as the nature, extent, and severity of his service-connected bilateral hearing loss and residuals of a fracture of the distal left scaphoid, the impact of those conditions on his ability to work. The Veteran should be provided an appropriate amount of time to submit this lay evidence. 3. Schedule the Veteran for an appropriate VA examination(s) (or telehealth interview, review of the record, etc., if an in-person examination is not feasible), a physical examination is not necessary unless the examiner(s) deems it necessary, to determine the nature, onset, and likely etiology of his claimed liver disorder, to include Nash, and an enlarged liver; hypertension; chronic fatigue syndrome; thyroid disorder, to include hypothyroidism; rhinitis; and skin disorder. The entire claims file must be reviewed by the examiner(s). Then, based on the results of the examination(s), the examiner(s) is (are) asked to address each of the following questions: (a) Please state whether the symptoms of each claimed condition are attributable to a known clinical diagnosis. If the Veteran does not now have, but previously had any such condition, when did that condition resolve? (b) Is the Veteran's disability pattern consistent with: (1) a diagnosable but medically unexplained chronic multisymptom illness of unknown etiology, (2) a diagnosable chronic multisymptom illness with a partially explained etiology, or (3) a disease with a clear and specific etiology and diagnosis? (c) If, after examining the Veteran and reviewing the claims file, it is determined that the Veteran's disability pattern is either (2) a diagnosable chronic multisymptom illness with a partially explained etiology, or (3) a disease with a clear and specific etiology and diagnosis, then please provide an expert opinion as to whether it is related to a presumed environmental exposure experienced by the Veteran during service in Southwest Asia. (d) Is it at least as likely as not that any diagnosed disorder had its onset directly during the Veteran's service or is otherwise causally related to any event or circumstance of his service, including environmental exposures during service in Southwest Asia during the Persian Gulf War? (e) If not directly related to service on the basis of questions (b)-(d), is any medical condition proximately due to, the result of, or caused by any service-connected disability(ies)? (f) If not caused by another medical condition, has any disorder been aggravated (made permanently worse or increased in severity) by any service-connected disability(ies)? If yes, was that increase in severity due to the natural progress of the disease. In responding to the above inquiries, please acknowledge and discuss any reports by the Veteran of fatigue; allergy problems and/or respiratory problems, and skin problems, as well as symptoms he thought were due to liver problems and/or hypertension, during and since service. 4. Schedule the Veteran for a VA examination (or telehealth interview, review of the record, etc., if an in-person examination is not feasible) to determine the extent and severity of his bilateral hearing loss. The claims file must be reviewed by the examiner. All indicated tests should be conducted and all signs and symptoms of the service-connected bilateral hearing loss should be reported in detail. Also, the examiner must fully describe the functional effects of the Veteran's hearing loss. 5. Schedule the Veteran for a VA examination (or telehealth interview, review of the record, etc. if an in-person examination is not feasible) to determine the nature, extent, and severity of his service-connected residuals of a fracture of the distal left scaphoid. All indicated tests must be conducted, including x-ray, and all symptoms associated with the Veteran's service-connected residuals of a fracture of the distal left scaphoid must be described in detail. Specifically, the examiner must conduct a thorough orthopedic examination of the Veteran's service-connected residuals of a fracture of the distal left scaphoid and provide diagnoses of any pathology found. As to the Veteran's service-connected residuals of a fracture of the distal left scaphoid, any affected nerve(s) should be expressly identified. For each affected nerve, the examiner must specifically indicate whether the impairment is in the nature of a neuritis, a neuralgia, and/or paralysis. If paralysis of any nerve is identified, the examiner must indicate whether the paralysis is complete or incomplete and, if it is incomplete, whether the incomplete paralysis is best characterized as mild, moderate, moderately severe, or severe. STEVEN D. REISS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. D. Regan, 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.