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Federal Court Medical Summary, 2000-3500 Page File
Terri M. David is a Social Security Disability (SSD) professional and former SSA/Office of Hearings Operations (OHO) Senior Attorney Adjudicator.
Terri began as an Attorney Decision Writer in Nashville, TN in 2004. She was promoted in 2006 to a position at headquarters in falls Church, VA, where she adjudicated disability claims at the reconsideration level. While there, she began her career as an ODAR/OHO trainer and mentor to new adjudicating attorneys and decision writers.
In 2007, Terri worked as a Senior Attorney Adjudicator in Houston, TX. There, an opportunity to create training material and provide training to new attorneys and law interns became possible and increased exponentially based on her extensive training in Falls Church, VA. She went on to become a National Decision Writer Trainer in 2008, teaching the basics of the 5-Step Sequential Evaluation and persuasively writing legally defensible Administrative Law Judge (ALJ) decisions.
Terri began working as a Senior Attorney Adjudicator Trainer in 2010. She trainer new and experienced senior attorneys on how to improve adjudicating disability claims at the hearings level, prior to an ALJ hearing.
Terri M. David’s SSD training is focused on efficiently and accurately adjudicating disability claims and writing persuasive ALJ decisions. Now, Terri shares years of valuable experience as an adjudicator, trainer, and decision writer through training concentrated on expediting and winning cases, understanding SSD law, and efficiently maneuvering the SSD claims process.
Date: April 11, 2018
Claimant: Name, SSN
ALJ: Honorable Judge Name
Hearing Date: April 21, 2018
Issues: Can Claimant perform her past relevant work as a younger individual at the alleged onset date (AOD), closely approaching advanced age at the date of birth (DOB), or established onset date (EOD) with the residual functional capacity (RFC) discussed below. Impairments that are determinative of her ability to perform work are left shoulder osteoarthritis and anxiety, which affect both light and sedentary work activity at the AOD, age 50, and EOD.
Exhibits as of 4/9/2018, submitted eight days prior to hearing: 1A-13F
Evidence not submitted within 5-Day Rule: Evidence of refilled pain prescription that is already in the file; therefore; no need to hold record open.
Titles II and XVI Date of filing: 11/15/2016
Date Last Insured: 12/31/2017
Age: 49 at AOD (10/10/2016) and 50 on 6/30/2017 and possible EOD (7/15/2017)
Education: high school, communicates in English
PRW: meat packager, light and semiskilled work (6E), (DOT# 920.587-018)
1/24/2017-DDS Vocational Specialist Finding: Transferable Skills to Other Work- Not PRW (6E)
Date Last worked / SGA: 10/10/2016 (work in November does not rise to SGA) (4D)
Prior ALJ application or reopening issue: No
Alleged Impairments: Obesity, lumbar spine DDD, right shoulder osteoarthritis, and anxiety.
DAA Issues: No
MEDICAL EVIDENCE OF RECORD
1F/1-74: Memorial Hermann Hospital and Sports Medicine, Dr. M. Wright, 1/2016-12/2016
1F/1 – 1/2/2016: Progress notes show elevated blood sugar at 210 and elevated blood pressure at 130/95.
1F/7 – 2/5/2016: Lumbar spine MRI confirms moderate degenerative disc disease at L5-S1 with spur. He is prescribed Tramadol. DX: lumbar spine degenerative disc disease.
1F/9-12 – 5/5/2016: Claimant is prescribed physical therapy and Tramadol is increased to twice per day.
1F/14-16 – 5/15/2016: Claimant reports back pain increases with physical therapy. A physical examination reveals limited range of motion of the lumbar spine and difficulty bending and stooping. A heat pad is applied for relief after physical therapy.
1F/21-24 – 7/21/2016: A physical therapy discharge summary shows Claimant made some progress and was compliant throughout treatment. There is some concern he continues to have low back pain when standing or sitting for prolonged periods of time. Claimant is instructed to return if pain exacerbates within the next few months.
1F/26-27 – 7/25/2016: Claimant is prescribed Insulin for uncontrolled diabetes, which is indicative of a worsening condition. He reports to Dr. Wright that he still has back pain and unable to lift heavy objects or shop for long periods of time.
1F/30-33 – 8/15/2016: Dr. Wright prescribes narcotic pain medication, oxycodone, for Claimant’s increasing back pain. Claimant requests additional physical therapy. Dr. Wright prescribes additional physical therapy that includes treatment twice per week for six weeks.
1F/40-65 – 8/25/2016 – 10/7/2016: Claimant participates in physical therapy and makes some progress. However, he reports radiating back pain down the right leg.
1F/67-69 – 10/15/2016: Claimant undergoes lumbar spine epidural steroid injection.
1F/71-72 – 11/23/2016: Blood pressure is stable on medication. However, blood sugars continue to fluctuate despite Insulin treatment. His back pain worsens with activity. An EMG/NCS is ordered.
1F/73-74 - 12/10/2016: EMG/NCS confirms radiculopathy at L5-S1. Claimant is prescribed Flexeril in addition to oxycodone.
2F/1-34: Pain Specialist, Dr. S. Charleston, 10/2016-6/2017
2F/2-5 – 10/15/2016: Claimant undergoes an epidural steroid injection. Claimant signs a narcotic contract. Claimant agrees to only take narcotics prescribed by Dr. Charleston, which he complies.
2F/7-9 – 11/28/2016: A physical examination shows reduced range of motion of the spine with a positive straight leg raise test on the right. Claimant reports some relief with rest and avoiding activities that require prolonged walking.
2F/10-13 – 2/4/2017: Claimant undergoes a second epidural steroid injection for ongoing back pain. There is some improvement with radiculopathy but flares-up with prolonged sitting and walking.
2F/14-16 – 2/25/2017: A follow-up examination shows some improvement with the injection; however, Claimant fell on a loose plank on his deck and exacerbated back pain. He also sprained his right wrist when he fell.
2F/21-24 – 3/9/2017: Dr. Charleston recommends a spinal stimulator for chronic back pain and Claimant agrees. Spinal stimulator is ordered. He is prescribed physical therapy for right wrist pain. He is dominant right hand. Claimant complains a right wrist injury makes it even more difficult for him to perform chores around the house.
2F/25-28 – 5/13/2017: Claimant reports improvement in the right wrist. However, he continues to disrupt sleep with tingling and numbness at night. His radiculopathy has improved with the stimulator; his pain continues to be moderate rated at a 5 on a worsening scale from 1 to 10. His medications include oxycodone and Flexeril. Physical therapy has improved right wrist pain; however, pain flares-up when lifting heavy objects.
2F/30-33 – 6/12/2017: A physical examination shows limited range of motion of the spine and right wrist. Treatment consists of narcotic pain medication, spinal stimulator, and right wrist splint.
3F/1-7: DDS Consultative Examination, 4/2017
3F/1: Claimant arrives accompanied by his spouse. He describes a progressively worsening back pain that led to him going on short-term disability a few months ago. Conservative treatment is not resolving pain, and he is considering back surgery. His spouse indicates doing all the chores because Claimant’s pain exacerbates with activity. She further reports Claimant could help with some chores until he sprained his right wrist that has not fully healed.
3F/2-3: Consultative examiner indicates a lumbar spine MRI shows degenerative disc disease with mild nerve encroachment at L5-S1. A physical examination shows limited range of motion of the spine and right wrist. He was able to walk on heels and toes but unable to squat. He had a negative straight leg raise test. Claimant’s blood pressure was elevated at 130/85. He weighs 231 pounds at five feet, 10 inches (BMI at 33.1), which is considered obese.
3F/4-5: Claimant is diagnosed with lumbar spine degenerative disc disease and right wrist sprain. Notably, the consultative examiner fails to consider Claimant’s obesity and hypertension.
3F/5-6: Consultative examiner includes a MSS indicating Claimant can lift 20 pounds, sit for three hours, stand/walk for four hours, and avoid climbing ladders, ropes, and scaffolds. The consultative examiner fails to reflect Claimant’s obesity and does not include additional right wrist limitations such as repetitive twisting and handling.
4F/1-7: State Medical Imaging, 5/1/2017 – 8/2017
4F/1 - 6/19/2018 x-ray: cervical spine xray showing fusion and disc space bone plug
4F/2-3 - 8/8/18 office visit note: back pain radiating down bilateral legs s/p “extensive” injections with pain in lifting, bending, pushing, pulling. Positive SLR bilaterally DX: lumbar spine degenerative disc disease and degenerative facet disease at L4-5 with severe back pain – surgical candidate for fusion at L4-5.
4F/3-5 DUPS 3F/2-3
4F/6-7 - 8/16/2018 MRI: L2/3, L3/4, L4/5 degenerative spondylosis with posterior disc bulging; moderate facet arthritis L3/4; severe bilateral facet arthritis L4/5; disc extrusion contacting Left S1 nerve. Injections for 2.5 years have not helped. Pain is worse when walking and standing. DX: lumbar spine spondylolisthesis.
4F/7 - 10/19/2018 office visit note: back pain with radiculopathy and antalgic gait. Claimant wants to proceed with two-level decompression and fusion at L3-4 and L4-5.
5F/1-10: DDS Psychological Consultative Examination, 2/28/2017
5F/1 – HS education, last employed in 2011 – worked as a warehouse worker for 25 years. He receives counseling at Houston Health. Claimant meets with his psychiatrist every month and therapist every one to two weeks. Medications include Lexapro, Ativan, and Ambien.
5F/2 – Current Functioning – poor sleep, increased appetite, social withdrawal, diminished sense of pleasure, fatigue, excessive worry, difficulty concentrating, restlessness, panic attacks several times per month, memory problems. Remote history of marijuana use.
5F/3-4 – MSE: cooperative, tearful, affect was “markedly dysphoric” and moderately depressed. He was unable to complete serial 3s. Memory impaired secondary to depression and anxiety. Average intellectual functioning. Fair insight and judgment. Activities of daily living: Able to perform simple tasks, errands, manage money. DX: Generalized anxiety disorder, depression, Panic Disorder, Post-traumatic stress disorder. Prognosis is guarded due to chronic nature of impairments.
5F/6-8: MSS: Claimant had moderate limitations in his ability to make judgments; understand, remember, and carrying out complex instructions; make complex work decisions; interact with public, supervisors, and coworkers; and respond to usual work situations and changes in work routine. The consultative examiner elaborated the restrictions stem from intrusive thoughts, anxiety with panic attacks, and memory problems.