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?
[ ] Yes [X] No
8. Remarks, if any:
-------------------
The Veteran is claiming service connection for hemorrhoids.
Opinion: It is as least as likely as not that the Veteran's
hemorrhoids
are proximately due to his service connected Crohn's disease.
Rationale: The C file was reviewed.
The STRs do document the rectal bleeding and the Crohn's
disease.
He has frequent diarrhea and some constipation; this in and
of itself is
prone to lead to hemorrhoid problems, which were clearly seen
and palpated
on today's exam.
Also, colonoscopy in 2009 did visualize internal hemorrhoids.
Thus, the service connection is substantiated
100% PTSD
100% Back
60% Bladder Issues
50% Migraines
30% Crohn's Disease
30% R Shoulder
20% Radiculopathy, Left lower 10% Radiculopathy, Right lower
10% L Knee 10% R Knee Surgery 2005&2007
10% Asthma
10% Tinnitus
10% Damage of Cranial Nerve II
Question
Navy04
Below is the C&P results from my Hemorrhoids exam secondary to Crohns Disease. What % do you guys think I will get. Thank you so much and God Bless!!!
Indicate method used to obtain medical information to complete
this document:
[X] In-person examination
Evidence review
---------------
Was the Veteran's VA claims file reviewed?
[X] Yes [ ] No
If yes, list any records that were reviewed but were not
included in the
Veteran's VA claims file:
VA medical records.
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
Date of diagnosis: 2013-14
2. Medical History
------------------
a. Describe the history (including onset and course) of the
Veteran's rectum
or anus conditions (brief summary):
The Veteran was diagnosed with Crohn's disease during
military service
in 2009.
He has had problems with frequent diarrhea and rectal
bleeding.
Last year he underwent diagnostic anoscopy with normal
results,
He was prescribed Analpram HC, which is hypdrocortisone
with pramoxine,
in an injectable rectal foam preparation.
Currently the hemorrhoids are actively inflamed and
symptomatic.
He also takes daily oral Psyllium to help prevent
constipation.
b. Does the Veteran's treatment plan include taking continuous
medication for
the diagnosed conditions?
[ ] Yes [X] No
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 moderate
If checked, describe:
Pain, itching, bleeding
4. Exam
-------
Provide results of examination of rectal/anal area: (check all
that apply)
[X] Small or moderate external hemorrhoids
[X] Other, describe:
Perianal inspection reveals diffuse moderate external
hemorrhoids
which become thrombotic/bluish when straining down,
no fissures
or fistulae.
DRE reveals normal sphincter tone, moderate sized
internal
hemorrhoids without prolapse or thrombosis, and no
other masses
in the rectal vault.
5. Other pertinent physical findings, complications, conditions,
signs and/or
symptoms
a. Does the Veteran have any scars (surgical or otherwise)
related to any
conditions or to the treatment of any conditions listed in
the Diagnosis
section above?
[ ] Yes [X] No
b. Does the Veteran have any other pertinent physical findings,
complications, conditions, signs and/or symptoms related to
any conditions
listed in the Diagnosis section above?
[ ] Yes [X] No
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: 2/11/2015
Hemoglobin: 15.8
Hematocrit: 44.3
White blood cell count: 5.1
Platelets: 191.0
[X] Other, specify: Sed Rate
Date of test: 2/11/2015
Results: 3 (normal)
b. Have imaging studies or diagnostic procedures been performed
and are the
results available?
[X] Yes [ ] No
If yes, provide type of test or procedure, date and
results (brief
summary):
See above.
Colonoscopy 8/19/2009--internal hemorrhoids visualized
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?
[ ] Yes [X] No
8. Remarks, if any:
-------------------
The Veteran is claiming service connection for hemorrhoids.
Opinion: It is as least as likely as not that the Veteran's
hemorrhoids
are proximately due to his service connected Crohn's disease.
Rationale: The C file was reviewed.
The STRs do document the rectal bleeding and the Crohn's
disease.
He has frequent diarrhea and some constipation; this in and
of itself is
prone to lead to hemorrhoid problems, which were clearly seen
and palpated
on today's exam.
Also, colonoscopy in 2009 did visualize internal hemorrhoids.
Thus, the service connection is substantiated
100% PTSD
100% Back
60% Bladder Issues
50% Migraines
30% Crohn's Disease
30% R Shoulder
20% Radiculopathy, Left lower 10% Radiculopathy, Right lower
10% L Knee 10% R Knee Surgery 2005&2007
10% Asthma
10% Tinnitus
10% Damage of Cranial Nerve II
10% Scars
SMC S
SMC K
OEF/OIF VET 100% VA P&T, Post 911 Caregiver, SSDI
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