Citation Nr: 21041040 Decision Date: 07/07/21 Archive Date: 07/07/21 DOCKET NO. 16-44 267 DATE: July 7, 2021 ORDER Entitlement to service connection for a right ankle disability is denied. Entitlement to a compensable disability rating prior to November 30, 2020, and in excess of 30 percent thereafter, for pseudofolliculitis barbae (PFB) is denied. REMANDED Entitlement to service connection for a left eye disability is remanded. Entitlement to service connection for a right eye disability is remanded. Entitlement to service connection for a right knee disability is remanded. Entitlement to service connection for G6PD deficiency is remanded. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that the Veteran has had a right ankle disability, to include pain resulting in a compensable level of functional limitation, at any time during or approximate to the pendency of the claim. 2. Prior to November 30, 2020, the Veteran's PFB did not affect at least 5 percent of his entire body or of the exposed area affected; medication was not prescribed to treat the Veteran's PFB any point. 3. From November 30, 2020, the Veteran's PFB has not resulted in visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features, four or five characteristics of disfigurement, PFB affecting more than 40 percent of the entire body or of exposed areas, or any systemic therapy. CONCLUSIONS OF LAW 1. The criteria for service connection for a right ankle disability have not been satisfied. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for a compensable disability rating for PFB prior to November 30, 2020, and in excess of 30 percent, thereafter, have not been satisfied. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.118, Diagnostic Codes 7800 to 7806. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1985 to May 1995; from January 14, 2004 to May 31, 2004; from August 2004 to August 2005; from October 31, 2006 to January 15, 2007; from July 21, 2007 to September 15, 2007; from June 23, 2008 to September 30, 2008; from October 10, 2008 to April 2, 2009; from October 26, 2009 to April 22, 2010; from June 26, 2012 to February 15, 2013; and from June 30, 2017 to May 25, 2018. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2014 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). The issues were previously before the Board in January 2020, where they were remanded for additional development, and now return for further appellate review. The Board notes that the Veteran's G6PD deficiency claim, addressed in the Remand section of this decision below, was initially denied by the RO in November 2011. The claim was again denied in the January 2014 rating decision on appeal, as the RO determined that new and material evidence had not been received sufficient to reopen the claim. While the RO reopened the Veteran's claim during the appeal in a subsequent rating decision, the Board must itself determine whether new and material evidence has been submitted. See Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001); Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996); Wakeford v. Brown, 8 Vet. App. 237 (1995). However, new and material evidence is not required to reopen a claim when, after a final decision, VA receives relevant official service department records that existed and had not been associated with the claims file when VA first decided the claim. 38 C.F.R. § 3.156(c). In this case, multiple additional service treatment records have been obtained and associated with the claims file. These records were not associated with the claims file at the time of the original denial and are relevant to the claim as they relate to the Veteran's claimed in-service injury. Golz V. Shinseki, 590 F.3d 1317 (Fed. Cir. 2010). Thus, new and material evidence is not required, and the claim for a G6PD deficiency may be considered de novo. 38 C.F.R. § 3.156(c). The Veteran testified before the undersigned Veterans Law Judge in August 2019. Neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist. 1. Service connection for a right ankle disability. The Veteran contends that he has a right ankle disability that is related to service. During a VA examination in December 2013 for his initial service connection claim, he reported that he injure both ankles after falling during a recent deployment. While the Board notes that it granted a separate service connection claim for the Veteran's left ankle in its previous decision in January 2020, as he was indeed shown to have arthritis of the left ankle manifest to a compensable degree within one year of discharge from that particular period of service, the claim for a right ankle disability has remained denied due to the presence of a current disability for service connection purposes. The Board concludes that the evidence continues to be against a finding that the Veteran has a current diagnosis of a right ankle disability and has not had one at any time during the pendency of the claim or recent to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). An additional VA examination in February 2015 continued to be absent for any right ankle disability, and more recent diagnostic testing of the ankle in August 2019 indicated no significant abnormalities. While the Board acknowledges a history of complaints of bilateral ankle problems in the Veteran's treatment records, he has only reported ankle pain without more. No record, including his hearing testimony before the undersigned, suggests that right ankle pain has resulted in any functional impairment. See Saunders v. Wilkie, 886 F.3d 1356, 1367-68 (Fed. Cir. 2018) (finding pain resulting in functional impairment, even if there is no identified underlying diagnosis, can constitute a disability); Martinez-Bodon v. Wilkie, 32 Vet. App. 393, 398 (2020) (finding that the holding in Saunders is not limited to pain alone, but rather, the definition of "disability" in 38 U.S.C. § 1110 (and by implication 38 U.S.C. § 1131) and includes any condition that results in functional impairment of earning capacity). Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. See 38 U.S.C. § 1131. In the absence of proof of a current diagnosis of the claimed disability, service connection for that disability cannot be established. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). As such, the Veteran's claim must be denied. The Board has considered the Veteran's statements, to include his assertions that he has a right ankle disability that is related to service. As the Veteran is not shown to have medical education or experience, he is a lay person and is competent to report (1) symptoms that are observable to a layperson, e.g., pain; (2) symptoms at the time supporting a later diagnosis by a medical professional; or (3) a contemporaneous medical diagnosis. See Davidson v. Shinseki, 581 F.3d 1313 (2009). The Veteran is not competent to independently render a medical diagnosis or opine as to the specific etiology of a condition as these are medically complex issues. Thus, his lay assertions do not constitute evidence upon which service connection can be granted. In any event, the Board ultimately assigns greater probative weight to the medical evidence of record, to include the findings rendered by a trained medical professional based on appropriate diagnostic testing and reasonably drawn conclusions with supportive rationale. In reaching the above conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable in this case. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. A compensable rating for PFB prior to November 30, 2020, and in excess of 30 percent, thereafter. Disability ratings are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Different ratings may be assigned for different periods of time for the same disorder if the facts show distinct time periods with different levels of disability. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). If two ratings are potentially applicable, the higher rating will be assigned if the disability more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. See 38 C.F.R. § 4.3. The Veteran is currently assigned a noncompensable rating for his PFB prior to November 30, 2020, and 30 percent for the period thereafter, pursuant to 38 C.F.R. § 4.118, Diagnostic Code 7800. This appeal stems from a claim for an increased rating filed in January 2013. The Board will consider the severity of his PFB disability from January 2013 as well as whether there was a factually ascertainable increase in severity within the year preceding his increased rating claim. See 38 C.F.R. § 3.400(o)(2). Throughout the appeal period, the Veteran's PFB has been rated under diagnostic code 7800 under 38 C.F.R. § 4.118, pertaining to ratings of the skin, which pertains scars or disfigurement of the head, face, or neck. The Board will nevertheless consider rating the service-connected PFB under any applicable diagnostic code. Diagnostic Codes 7800 to 7805 pertain to scars. 38 C.F.R. § 4.118. The Schedule of ratings for the skin were amended effective August 13, 2018. See 83 Fed. Reg. 32,592 (July 13, 2018). Prior to August 13, 2018, the Board will consider the old version of the diagnostic codes only (old code); however, for the period beginning August 13, 2018 the Board will consider both the old and amended version (amended code) of the diagnostic codes and rate based on whichever is most favorable to the Veteran. Diagnostic Code 7800 deals with scars and disfigurement of the head, face, or neck and was not revised by the recent regulatory amendments. A 10 percent rating is assigned with one characteristic of disfigurement. A 30 percent rating is assigned with visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with two or three characteristics of disfigurement. A 50 percent rating is assigned with visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features, or; with four or five characteristics of disfigurement. An 80 percent rating is assigned with visible or palpable tissue loss and either gross distortion or asymmetry of three or more features or paired sets of features, or; with six or more characteristics of disfigurement. Characteristics of disfigurement include: Scar 5 or more inches (13 or more cm.) in length; Scar at least one-quarter inch (0.6 cm.) wide at widest part; Surface contour of scar elevated or depressed on palpation; Scar adherent to underlying tissue; Skin hypo-or hyper-pigmented in an area exceeding six square inches (39 sq. cm.); Skin texture abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches (39 sq. cm.); Underlying soft tissue missing in an area exceeding six square inches (39 sq. cm.); and, Skin indurated and inflexible in an area exceeding six square inches (39 sq. cm.). Diagnostic Code 7801 provides for a 10 percent disability evaluation for a scar that is not of the head, face, or neck, that is deep and nonlinear (old code) or associated with underlying soft tissue damage (amended code), and that has an area of at least 6 square inches (39 sq. cm.). Higher ratings are available if larger areas are affected. Under the old code, a "deep scar" is defined as one associated with underlying soft tissue damage. The old and amended codes also differ regarding instructions for totalling the area affected when there is more than one qualifying scar. Diagnostic Code 7802 provides for a 10 percent disability evaluation for a scar not of the head, face, or neck, and is inapplicable here. Diagnostic Code 7804 provides for a 10 percent disability evaluation for one or two scars that are unstable or painful. A 20 percent disability evaluation is assigned where there are three or four scars that are unstable or painful. A 30 percent disability evaluation is assigned where there are five or more scars that are unstable or painful. An unstable scar is one where there is frequent loss of skin covering over the scar. If one or more scars are both unstable and painful 10 percent is added to the evaluation. Under the new and amended codes, pursuant to Diagnostic Code 7805, a scar may be rated on any disabling effect(s) not considered as part of Diagnostic Codes 7800 to 7804. The Board also notes that PFB is defined as erythematous follicular papules or, less commonly pustules resulting from close shaving of very curly hair. Stedman's Medical Dictionary, 27th ed. at 1470. Dermatitis is inflammation of the skin. Id., at 479. Eczema is the generic term for inflammatory conditions of the skin, particularly with vesiculation in the acute stage, typically erythematous edematous, papular, and crusting. Id., at 566. Thus, as the symptoms of PFB are similar to those of eczema, and can include disfigurement of the face and neck, rating the Veteran's PFB under Diagnostic Code 7806 is also appropriate in this case. See Butts v. Brown, 5 Vet. App. 532 (1993). Under the pre-August 2018 rating criteria, Diagnostic Code 7806 provided for a 0 percent (noncompensable) rating where there is less than 5 percent of the entire body or less than 5 percent of exposed areas affected, and; no more than topical therapy required during the past 12-month period. A 10 percent rating is assigned where there is involvement of at least 5 percent, but less than 20 percent, of the entire body or at least 5 percent, but less than 20 percent, of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. A 30 percent rating is assigned for dermatitis or eczema affecting 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas, or for dermatitis or eczema that requires systemic therapy, such as corticosteroids or other immunosuppressive drugs, for a total duration of six weeks or more, but not constantly, during the past 12-month period. A 60 percent disability rating is assigned for dermatitis or eczema, affecting more than 40 percent of the entire body or more than 40 percent of exposed areas, or for dermatitis or eczema that requires constant or near-constant systemic therapy, such as corticosteroids or other immunosuppressive drugs, during the past 12-month period. 38 C.F.R. § 4.118. Under the post-August 2018 rating criteria, a 0 percent rating is assigned when there is no more than topical therapy required over the past 12-month period and characteristic lesions involving less than 5 percent of the entire body affected; or characteristic lesions involving less than 5 percent of exposed areas affected. A 30 percent rating is assigned for characteristic lesions involving more than 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected; or systemic therapy including, but not limited to, corticosteroids, phototherapy retinoids, biologics, photochemotherapy, (psoralen with long-wave ultraviolet-A light (PUVA) or other immunosuppressive drugs required for a total duration of 6 weeks or more, but not constantly, over the past 12-month period. A 60 percent rating is assigned for characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of exposed areas affected; or, constant or near-constant systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required over the past 12-month period. Id. Turning to the evidence, prior to the period on appeal beginning November 30, 2020 the Veteran was afforded two VA skin examination for his PFB claim, in December 2013 for his initial increase rating claim, and again in February 2015. At each examination he reported exacerbation with his PFB after shaving. Neither examination, however, indicated that his PFB at the time covered any percentage of the total body area or exposed area affected, or any scarring. He also reported no medical treatment for his PFB at either examination, to include oral or topical medications. His medical treatment records during this period on appeal are not in significant conflict with the above VA examination findings. Based on the foregoing, and with consideration of his lay statements that his PFB is exacerbated by excessive shaving, the Board finds that the Veteran's current noncompensable percent rating during this period on appeal is proper. The only possible diagnostic codes that could afford the Veteran a higher rating are Diagnostic Codes 7800, 7804, 7805, and 7806. There is no competent and credible medical evidence that the Veteran's PFB manifested scarring of the face or neck with one characteristics of disfigurement (7800), one or two unstable or painful scars (7804), any disabling effects of his PFB (7805), or characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected, or the requirement of systemic therapy (7806). 38 C.F.R. § 4.118. During the Veteran's hearing before the undersigned, the Veteran asserted that his PFB had worsened. Thus, and pursuant to the Board's previous remand, and additional VA examination was afforded in November 2020. The Veteran reported painful, itchy, bumpy skin that interfere with concentration and made it uncomfortable to wear a mask. Indeed, the examiner observed hyperpigmentation and raised, itchy lesions associated with the Veteran's PFB that covered less than percent of the total body area and total exposed area affected. It was also noted that the Veteran used Witch Hazel to as treatment for 6 weeks or more during the past 12 months, but not constant, and that he did not use any systemic therapy. The examiner also observed that the Veteran now had a scar associated with his PFB that was elevated and tender on palpation, hyperpigmented, and measuring 3 centimeters by 10 centimeters. There are no medical treatment records in significant conflict with the above examination findings. Based on the foregoing, the Veteran's PFB rating was increased to 30 percent effective November 30, 2020, the date of the examination based on the amended criteria, specifically, Diagnostic Code 7800. The examination noted two characteristics of disfigurement an elevated, hyperpigmented scar. As the evidence for this period has not indicated visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features, four or five characteristics of disfigurement, PFB affecting more than 40 percent of the entire body or of exposed areas, or any systemic therapy, a rating higher than 30 percent is not warranted under either the old or amended criteria. 38 C.F.R. § 4.118, Diagnostic Codes 7800, 7806. In sum, as the evidence is against a finding that higher ratings are warranted, the claim for entitlement to a compensable disability rating for PFB prior to November 30, 2020, and in excess of 30 percent, thereafter, must be denied. The Board is sympathetic to the Veteran's lay statements that his disability is worse than currently evaluated and those statements have been considered. The Veteran is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses. Layno v. Brown, 6 Vet. App. 465 (1994). He is not, however, competent to identify a specific level of disability according to the appropriate diagnostic codes. Such competent evidence concerning the nature and extent of the Veteran's disability have been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports and the clinical records) directly address the criteria under which the disability is evaluated. The medical and lay evidence has been assessed by the Board in determining the overall disability rating. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. REASONS FOR REMAND While the Board regrets further delay, the Veteran's remaining service-connection claims for bilateral eye disabilities, a right knee disability, and a G6PD deficiency must be remanded for additional development. 1. Service connection for bilateral eye disabilities. For purposes of entitlement to benefits, the law provides that refractive errors of the eyes are developmental defects and not disease or injury within the meaning of applicable legislation. 38 C.F.R. §§ 3.303(c), 4.9. In the absence of superimposed disease or injury, service connection may not be allowed for refractive error of the eyes, including myopia, presbyopia, anisometropia, hyperopia, and astigmatism, even if visual acuity decreased in service, as this is not a disease or injury within the meaning of applicable legislation relating to service connection. 38 C.F.R. §§ 3.303(c), 4.9; VA Manual M21-1, Part VI, Subchapter II, para. 11.07. Thus, VA regulations specifically prohibit service connection for refractory errors of the eyes unless such defect was subjected to a superimposed disease or injury which created additional disability. See VAOPGCPREC 82-90, 55 Fed. Reg. 45,711 (1990) (service connection may not be granted for defects of congenital, developmental or familial origin, unless the defect was subject to a superimposed disease or injury). The Veteran asserts that he has bilateral eye disabilities that are related to service. He reported during his hearing before the undesigned that he was poked in the eye a number of times playing basketball but did not report it to any medical provider. His VA treatment records, however, do note the Veteran reporting the same assertion to medical providers in June 2016. He also stated that he was struck in the eye twice with an elbow, for which he did seek treatment. While a VA examiner in February 2015 did not diagnose an eye condition that was not a congenital or developmental error of refraction, his more recent medical records reflect a diagnosis of open angle glaucoma and mild dry eye syndrome, bilaterally, which is not considered a congenital or developmental error of refraction. See April 6, 2018 re-deployment Report of Medical History. Records also reflect treatment with Latanoprost eye drops, first prescribed in September 2015. No opinion is of record, however, as to whether current originated during service or is otherwise etiologically related to service, to include superimposed over any congenital defect. As such, remand is required to afford the Veteran a new VA eye examination. The Board also notes that the Veteran asserted in an April 2016 VA Form 21-526EZ that his bilateral eye disabilities are related to environmental hazards while deployed overseas. The record reflects that the Veteran served in Kyrgyzstan, and while he has not been specific as to which environmental exposures he was exposed to, he recently submitted a Department of the Air Force Memorandum discussing the health hazards of burn pits. While on remand, and prior to scheduling the Veteran's medical examination, the RO should conduct any development necessary to determine the Veteran's environmental hazard exposure during service, if any. 2. Service connection for a right knee disability. Similar to the Veteran's service connection claim for a right ankle disability, the Veteran's claim for a right knee disability, which he also asserts is the result of the same 2012 fall for which his left knee disability is currently service-connected, has been denied based on the absence of a current disability. As such, no etiological opinion has been provided as to this purported disability. In contrast to the ankle claim, however, recent X-ray findings in August 2019 do indicate right knee osteoarthritis. As such, remand is necessary to afford the Veteran new VA ankle examination and obtain a medical opinion. 3. Service connection for a G6PD deficiency. The Veteran's medical records, including his STRs, indicate that he has a glucose-6-dehydrogenase deficiency, defined as the most common inborn error of metabolism; an X-linked enzyme deficiency. See Dorland's Illustrated Medical Dictionary 790 (32nd ed. 2012). Essentially, this is an inherited condition in which the body does not have an adequate amount of the G6PD enzyme, which helps red blood cells function normally. In general, service connection may not be granted for congenital or developmental defects such as G6PD deficiency, as they are not considered a disease or injury for the purpose of service connection. See 38 C.F.R. § 3.303 (c), 4.9 (2018). For VA purposes, a "defect" is defined as a structural or inherent abnormality or condition which is more or less stationary in nature and is generally incapable of improvement or deterioration. However, service connection may be granted for any additional disability that results where a congenital or developmental defect is subject to, or aggravated by, a superimposed disease or injury. See VAOPGCPREC 82-90 (July 18, 1990); VAOPGCPREC 67-90 (July 18, 1990). While the examiner noted the congenital nature of the Veteran's condition, it was only noted that it was "asymptomatic and is not aggravated by military service," with nothing further, and no physical hematic disorder examination was afforded to the Veteran. During his hearing before the undersigned, he described a history of muscle and joint pain, but was uncertain of their relationship to his G6PD deficiency. The Board finds that a new examination is warranted because the evidence is insufficient to allow the Board to determine whether the G6PD deficiency is a congenital disease or defect and, if the latter, whether any other disease or injury was superimposed upon it as a result of service. If G6PD deficiency is determined to be a disease, then the presumption of soundness is applicable and should be addressed, i.e., whether there is clear and unmistakable evidence that (1) the G6PD deficiency preexisted service and, if so, (2) whether it was not aggravated by service beyond its natural progression. 38 C.F.R. § 3.304(b); Quirin v. Shinseki, 22 Vet. App. 390, 396 (2009) (citing Monroe v. Brown, 4 Vet. App. 513, 515 (1993)) (the presumption of soundness applies to congenital diseases). The matter is therefore REMANDED for the following action: 1. Ask the Veteran to identify all outstanding treatment records relevant to his remanded claims. All identified VA records should be added to the claims file. All other properly identified records should be obtained if the necessary authorization to obtain the records is provided by the Veteran. If any records are not available, or the Veteran identifies sources of treatment but does not provide authorization to obtain records, appropriate action should be taken (see 38 C.F.R. § 3.159(c)-(e)), to include notifying the Veteran of their unavailability. 2. Conduct any development necessary to determine what, if any, environmental exposures the Veteran was referring to in his April 2016 VA Form 21-526EZ in relation to his service connection claims for bilateral eye disabilities, including asking the Veteran to submit ana additional statement. 3. Schedule the Veteran for a VA examination to determine whether it is at least as likely as not (50 percent probability or greater) that any current eye condition onset during service or is otherwise related to an in-service injury, event, or disease, to include exposure to herbicide agents. For any diagnosed refractive error, the examiner should address whether it was a resultant disability that occurred as a result of superimposed disease or injury, to include the Veteran's asserted exposure to environmental hazards. The examiner should elicit a full history from the Veteran and consider the lay statements of record. The Veteran is competent to attest to factual matters of which he has first-hand knowledge, and if there is a medical basis to support or doubt the history provided by the Veteran the examiner should provide a fully reasoned explanation. A rationale for all opinions expressed is requested as adjudicators are precluded from making any medical findings. 4. Schedule the Veteran for a VA examination to determine whether it is at least as likely as not (50 percent probability or greater) that any current disability of the right knee onset during service or is otherwise related to an in-service injury, event, or disease, to include an in-service fall in 2012 for which his currently-service-connected left knee disability is attributed. The examiner should elicit a full history from the Veteran and consider the lay statements of record. The Veteran is competent to attest to factual matters of which he has first-hand knowledge, and if there is a medical basis to support or doubt the history provided by the Veteran the examiner should provide a fully reasoned explanation. A rationale for all opinions expressed is requested as adjudicators are precluded from making any medical findings. 5. Schedule the Veteran for a VA examination to determine the nature and etiology of his G6PD deficiency. If possible, the examination should be conducted by a hematologist. The examiner is asked to provide responses to the following: (a) Is the Veteran's G6PD deficiency a congenital disease OR congenital defect? Defects are defined as "structural or inherent abnormalities or conditions that are more or less stationary in nature." VAOPGCPREC 82-90. A disease, on the other hand, is defined broadly as "any deviation from or interruption of the normal structure or function of any part, organ, or system of the body..." and "a condition considered capable of improving or deteriorating." Id. "Any worseningany change at allmight demonstrate that the condition is a disease, in that VA considers defects to be 'more or less' static and immutable." Quirin v. Shinseki, 22 Vet. App. 390, 395 (citing VAOGCPREC 82-90). In assessing whether a condition is a congenital disease or defect, the Board emphasizes that all evidence of record should be considered, including post-service medical records that could potentially show that the condition has worsened. The Veteran's lay statements should also be considered. (b) If it is determined that G6PD deficiency is a congenital disease, is there clear and unmistakable evidence that it preexisted service? (c) If it is determined that G6PD deficiency is a congenital disease that preexisted service, then is there clear and unmistakable evidence that it was not aggravated during active military service? The examiner should explain whether the evidence shows the G6PD deficiency was aggravated during active military service. If there was aggravation, the examiner should explain whether it was due to the natural progress of the condition. The Board notes for the examiner that the Veteran believes that inoculation shots or other medications during service may have aggravated his condition. (d) If it is determined that the G6PD deficiency is a congenital defect, then was there disease or injury superimposed upon it as a result of service? The Board notes for the examiner that the Veteran believes that inoculation shots or other medication during service may have aggravated his condition. (e) If the Veteran's G6PD deficiency is an acquired disorder, is it at least as likely as not that the disorder is etiologically related to symptomatology noted in service? The examiner should elicit a full history from the Veteran and consider the lay statements of record. The Veteran is competent to attest to factual matters of which he has first-hand knowledge, and if there is a medical basis to support or doubt the history provided by the Veteran the examiner should provide a fully reasoned explanation. A rationale for all opinions expressed is requested as adjudicators are precluded from making any medical findings. P.M. DILORENZO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. Scarduzio, 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.