C&P exam results

[Navy4life]

Here are my questions:

1. The pruritus ani is a symptom of the chronic diarrhea/IBS, whichI am s/c for.  So would the pruritus ani be secondary s/c to my IBS?

2.  The hemorrhoids which are mild/moderate will be 0% according to 7336 correct?

3.  The anal fissure, will that be rated separately? I ask this becasue the rating of 7336 discusses the anal fissure as it be related to hemorrhoids, however, the C&P exmainer is indicating the anal fissure is related to my IBS.

The rater asked for TWO opinions, one if my anal fissure was related to my IBS and the other question was if my hemmorrhoids were related to my IBS.  The C&P examiner said "at least as likely as not" for both.

Here is the C&P exam results:

 Rectum and Anus Conditions (including Hemorrhoids)

Disability Benefits Questionnaire  

Is this DBQ being completed in conjunction with a VA 21-2507, C&P  Examination Request?[X] Yes [ ] NoACE and Evidence Review

Indicate method used to obtain medical information to complete this document:[X] In-person examination

Evidence Review

Evidence reviewed (check all that apply):

[X] VA e-folder (VBMS or Virtual VA) [X] CPRS

1. Diagnosis

Does the Veteran now have or has he/ she ever had any condition of the rectum or anus?[X] Yes [ ] No

[X] Internal or external hemorrhoids ICD code: K64.8

Date of diagnosis: 09/ 15/ 1994

2.  Medical History

a.   Describe the history (including onset and course) of the Veteran's rectumor anus conditions (brief summary):The Veteran is claiming sc for hemorrhoids and anal fissuresThis is a 45 year old Female Veteran with the hisory of external and internal hemorrhoids, anal fissure had EUA, external hemorrhoidectomy and botox injection at  XXX Va on 03/ 10/ 2016. The Veteran reported some relief afterwards but presented again at WPB with recurrent anal pain and prolapsing of anal mass. She had again EUA, botox injection into internal anal sphincter and hemorrhoidectomy right and left posterior on 07/ 07/ 2016. She is exclusively followed by XXX VA- Gastroenterolgy for this condition.

The Veteran continues to endorse symptoms of sharp perianal pain and itching with minimal bleeding on defecation.

Surgery clinic follow up 8/8/16

On exam healing well but still tender. A/ P: recovering well but it appears that she has failed botox twice. Will ask XXX for a second opinion to consider sphincterectoly.09/ 15/ 1994: colonsoscopy- chronic diarrhea -STR small hemorrhoids. chronic use of laxatives2013:private doctors had colonoscopy done : external and internal hemorrhoids found.03/ 2016: first hemorrhoidectomy done at VA XXX one internal and external anal fissures: botox injection 07/ 07/ 2016: several external heamorrhoids removed and recieved one botox injection

b. Does the Veteran's treatment plan include taking continuous medication forthe diagnosed conditions? [X] Yes [ ] No 

If yes, list only those medications used for the diagnosed conditions: calmoseptine ointment for the prurius Ani Dilitiazem 2% ointment for anal fissure 

3. Signs and Symptoms

Does the Veteran have any findings, signs or symptoms attributable to any of the diagnoses in Section 1?[X] Yes [ ] No [X]

a. Internal or external hemorrhoids If checked, indicate severity (check all that apply): [X] Mild or moderateIf checked, describe:

History of hemorrhoids: internal and external. Had hemorrhoidectomy in March and July 2016. [X] With fissures

[X] f. Pruritus ani If checked, indicate underlying condition and describe:The veteran has history of pruritus ani and currently is on treatment with topical creams 

4. Exam

Provide results of examination of rectal/ anal area: (check all that apply) [X] No external hemorrhoids; skin tags only

5. Other pertinent physical findings, complications, conditions, signs, symptoms and scars

a. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to any conditions listed in the Diagnosis Section above?

[ ] Yes [X] No conditions or to the treatment of any conditions listed in the Diagnosis Section above?[ ] Yes [X] No c. Comments, if any: No response provided 6. Diagnostic testing 

a. Has laboratory testing been performed? [X] Yes [ ] No If yes, check all that apply: 

[X] CBC (if anemia due to any intestinal condition is suspected or present)

Date of test: 08/ 05/ 2016 Hemoglobin: 12.8Hematocrit: 38.8Platelets: 266 

b. Have imaging studies or diagnostic procedures been performed and are the results available?[ ] Yes [X] No 

c. Are there any other significant diagnostic test findings and/ or results? [ ] Yes [X] No 7.

Functional impact

Does the Veteran's rectum or anus condition impact his or her ability to work [No]

ACE and Evidence Review Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence Review

Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS MEDICAL OPINION SUMMARY

RESTATEMENT OF REQUESTED  OPINION: 

a. Opinion from general remarks: Is the Veteran's anal fissures at least as likely as not (50 percent or greater probability) proximately due to or the result of irritable bowel syndrome? 

Is the Veteran's Hemorrhoids at least as likely as not (50 percent or greaterprobability) proximately due to or the result of irritable bowel syndrome? 

b. Indicate type of exam for which opinion has been requested: DBQ Gen anus and rectal

TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR SECONDARY SERVICE CONNECTION ] 

a. The condition claimed is at least as likely as not (50% or greater probability) proximately due to or the result of the Veteran's service connected condition. 

c. Rationale: Current medical literature support irritable bowel syndrome Veteran has chronic diarrhea) as a cause or risk factor for the development of Anal fissure. https:// www.www.mayoclinic.org/ diseases.../ anal-fissure/ symptoms-causes/ dxc-2 016823 

Nexus between irritable bowel syndrome and Hemorrhoids well substantiated in the medical literature. Veteran has documented history of chronic diarrhea from IBS and Hemorrhoids. 

[Buck52]

Roger That Navy4... I deleted my last post.

[Navy4life]

Buck;

I just re-read the appeals you attached and I noticed this:

Moreover, post-service medical records do not show treatment for, or evidence of, large or thrombotic hemorrhoids, irreducible, with excessive redundant tissue, evidencing frequent recurrences to warrant a 10 percent evaluation for service- connected hemorrhoids under DC 7336.

^^Okay so that is me too.  I would not warrant the 10% either due to the mild/moderate comment in my C&P BUT it goes on to say this:

Resolving all doubt in the Veteran's favor, the Board finds that a 20 percent evaluation under DC 7336 is warranted for hemorrhoids with persistent bleeding and with secondary anemia, or with fissures. In this case, the medical evidence undoubtedly shows that the Veteran has hemorrhoids and an anal fissure, and the Board finds that the bleeding associated with his disability is considered "persistent," as the September 2005 VA examiner noted the Veteran's complaints of bleeding 50 percent of the time with bowel movements. Thus, although a compensable evaluation is not warranted for either hemorrhoids or the anal fissure when considered separately; when combined, the Board finds that the criteria for a 20 percent evaluation, the maximum available under DC 7336, are met or nearly approximated for hemorrhoids with persistent bleeding and an anal fissure.

^^She states I have the hemorrhoids, fissure, pruritus ani and minimal bleeding during bowel movements so again, I am not sure I would get the 20%.  I am hoping for at least 10% since I have so much going on down there LOL