Hartsell and Associates Legal Nurse Consultants Social Security Disability Sample

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IN THE CASE OF: _________________________, Claimant

DOB: June 04, 1955, Currently 52 years of age,
Now Approaching Advanced Age (50-54)

Step One: The Claimant has not been engaged in any “Substantial gainful activity (SGA) since May 15, 2004.
Therefore Step One has been met.

Step Two: The Claimant has to have a medically determinable impairment that is “severe” or a combination
of impairments that are “severe” (20CFR 416.920©). An impairment or combination of impairments is “severe”
within the meaning the regulations if it significantly limits an individual’s ability to perform basic work activities.

4.   Degenerative Disc Disease of Cervical Spine – September 2005. DDD of anterior and
      posterior spondylosis (immobility and fusion of vertebral joints) with straightening of spine
      at C4-5 and C5-6 diagnosed on 9/7/07.

5.   Major Depressive Disorder: October 8, 2004 – November 15, 2005. Diagnosed by ___ on
      5/11/01. _______ Mental Health has been treating patient since 2004. Ms _____ also
      diagnosed patient as major depressive disorder. In 2005, Dr._____ gave the diagnoses of
      Major depressive disorder recurrent and moderate.

7. Anxiety Disorder NOS - May 9, 2005 by _______, Ph.D, but diagnosed by Dr. ___ on 9/18/03
as Anxiety Disorder.

11. History of lateral epicondylitis of left elbow with bilateral arm pain from repetitive movements
      at work per Dr. _____ in February of 2004; at which time he restricted her activity to no
      repetitive lifting over 20 lbs., no pushing and/or pulling over 30 lbs of force, and pt must
      wear brace to the elbow. In 5/12/04, Dr. _____noted, left lateral epicondylitis, mild with
      history of persistent bilateral arm pain precipitated by repetitive activity, somewhat relieved
      with rest.

12. Hypothyroidism under treatment –10/19/04 by Dr. ___ with history of Goiter. Med = Levoxyl
75 mg daily.

13. Arthralgias – Dr. ____ had diagnoses of Arthralgias involving the cervical and lumbar spine
and upper extremities.

16. Large right sided pleural effusion – 06/04/1999 at __________ Hospital

17. Moderate coagulopathy with elevated Protime and decreasing platelets– 06/04/1999
at _____________Hospital

18. Cholestatic hepatitis picture with elevated total bilirubin and alkaline phosphatase–
06/04/1999 at __________ Hospital

19. Right sided heart failure with JVD (jugular vein distention) – 06/04/1999 at _______ Hospital

21. Total Abdominal Hysterectomy secondary to carcinoma in situ of the cervix

22. Hyperlipidemia – 10/19/04 per Dr. _____ with meds of Mevacor and Lipidor

24. Osteopenia of Lumbar Spine and hip with moderate increased risk of fracture – 2/27/02 by
Dr. _____.

25. Vaginal Dysplasia, status post previous hysterectomy for cervical disease/cervical cancer
and with Cervical Colposcopy and laser ablation of the vagina

27. Hypertension. On 9/7/07, her B/P was 162/102 and Dr. _____ advised her to see her primary
MD immediately.

32. History of Grave’s Disease (Graves disease is an autoimmune disorder that involves
overactivity of the thyroid gland) – 10/24/02 per __________ Hospital

These 32 diagnoses are significant and do significantly limit claimant’s ability to perform basic work activities. Her past
relevant work experience consisted of working in several different sewing factories as a general laborer. As stated by Dr. _____,
“By history, she has done manual type labor, and it appears that the claimant appears to have marked limitations in the ability
to do complex and detailed work. Ability to work with the public, concentrate and adapt appears to be moderately limited.
Certainly language could be a barrier.” He gave a diagnosis of borderline to low average intellectual functioning. Her
capabilities to perform the basic mental demands of unskilled work are so severely compromised that she cannot engage
in any activity on a regular basis for 8 hours/day and 5 days a week. (SSR 96-8p and 96-9p). Ms. _____ M.S. gave a diagnosis
of borderline to low intellectual functioning.

In 2002, she was diagnosed with Osteopenia of lumbar spine and hip with moderate increased risk of fracture. To date, this
condition has most certainly worsened. Also the Arthralgias of the neck and upper extremities and low back severely
compromise working 8 hours daily and 5 weekdays.

Claimant was born and went to school in the Philippines. She was the youngest of several children. Her parents died when
she was 3 years old. She was sent to live with an aunt who abused her mentally and physically and at times starved her.
She at some point also lived with an older sister and later with an older brother who did not treat her any better than the aunt.
She reports being sexually abused by a brother-in-law and one of his friends. She completed one year of high school at age 17,
got a job and was married by age 19.

English is her second language. She does not read or write well, even though she has lived in the U.S. for about 30 years.
Many times, she doesn’t understand what people are saying, but still nods her head and agrees. Ms.____has
difficulty understanding the questions that people ask of her. Claimant was given the PAI, but she was struggling
to understand, and she was having difficulty processing information, so that the testing was eventually discontinued.

On May 9, 2005, _______ Ph.D opined that the claimant would have difficulty understanding detailed instructions.
He thought her language difficulties would preclude working with the public.

On February 14, 2004 after having bilateral arm pain from repetitive movements at work, she went to Dr. _____.
He reported pain in the joint involving forearm, and he restricted her activity to no repetitive lifting over 20 lbs., no
pushing and/or pulling over 30 lbs. of force, and must wear brace to the elbow. On 5/12/04, Dr _____noted, left lateral
mild epicondylitis (irritation or inflammation of the epicondyle or surrounding tissue, esp. at the elbow) with history of
persistent bilateral arm pain precipitated by repetitive activity, somewhat relieved with rest.

On 9/7/07 she was diagnosed with worsening degenerative disc disease with anterior and posterior spondylosis (immobility
and fusion of vertebral joints), which limits the mobility of her neck. Also on that date, a diagnosis was given of right knee
osteoarthritis, which further limits claimant’s mobility. Now, her blood pressure is high at 162/102 when seen
by Dr. _____ on 9/7/07.

Along with the above severe impairments, Ms. _____ suffers from major depression and anxiety.
She feels worthless, helpless and hopeless, because she has no money to pay bills, from health related issues and inability
to receive proper medical care. She relates sleep disturbances, decreased appetite, has a hard time concentrating and is
nervous all of the time. States that many times, she wants to die. Claimant has been unable to seek proper medical treatment
due to lack of finances. She has been unable to go to _____ Mental Health, because she owes money and can’t pay.
Her last visit was 2 years ago, when they gave her meds of Celexa. Dr. _____ . gave Ms. _____ a diagnosis of
borderline to low intellectual functioning.

Step Three: The Claimant’s impairment or combination of impairments meets or medically equals the criteria of an impairment
listed in 20 CFR, Part 404, Subpart P, Appendix 1 (20 CFR 416.92 (d), 416.925, and 416.926). If the claimant’s impairment or
combination of impairments meets or medically equals the criteria of a listing and meets the duration requirement, the
claimant is disabled. Basically, is her condition found in the listings of disabling conditions? The answer is Yes.

#12.04 Affective Disorders. Characterized by a disturbance of mood, accompanied by a full or partial manic or depressive
syndrome. Mood refers to a prolonged emotion that colors the whole psychic life; it generally involves either depression or
elation. The required level of severity for these disorders is met when the requirements in both A and B are satisfied,
or when the requirements in C are satisfied.

     A. Medically documented persistence, either continuous or intermittent, of one of the
           following in A and B, or C.

          1.   Depressive syndrome characterized by at least four of the following:

          a.   Anhedonia or pervasive loss of interest in almost all activities; Ms.___states
                that she "just wants to stay at home", feels helpless and hopeless. Lives with
                daughter.

          b. Appetite disturbance with change in weight: Ms. ___ c/o of appetite disturbances,
                with decrease in appetite. In addition to depression effects, many meds cause
                decreased appetite.

          c.   Sleep disturbance: Has been on meds of Seroquel 25 mg at night. Seroquel is also
                psychotropic medication given for depression. One time a day doses are usually
                given at night because of the drowsiness side effect.

          d.   Psychomotor agitation or retardation.

          e.   Decreased energy: Has been on Lexapro 10 mg 2 tabs daily. Lexapro is for the
                treatment of major depressive disorders and generalized anxiety disorder. The
                most common side effects are insomnia, somnolence and increased fatigue.
                Increased fatigue occurs along with the loss of energy as most described with
                depression, as the patients describes.

          f.   Feelings of guilt or worthlessness: States that she feels worthless and hopeless,
               because she has no money to pay bills. States that she "wants to die".

          g.   Difficulty concentrating or thinking. Ms. _____ states that she has difficulty with the
                P.A.I., but she was struggling to understand, and she was having difficulty processing
                information, so that the testing was eventually discontinued. On May 9, 2005,   _______ Ph.D
                opined that the claimant would have difficulty understanding detailed  instructions. He
                thought her language difficulties would preclude working with the public. Ability to work
                with the public, concentrate and adapt appears to be moderately limited.

          h.   Thoughts of suicide: feelings of hopelessness precede thoughts of suicide, and Ms. ___
                 has these thoughts of helplessness and hopelessness. States that she just wants to die.

2. Manic syndrome characterized by at least three of the following: (doesn't apply to claimant).

g. Involvement in activities that have a high probability of painful consequences, which
are recognized; or

3.    Bipolar syndrome with a history of episodic periods manifested by the full symptomatic
       picture of both manic and depressive syndromes (and currently characterized by either
       or both syndromes); doesn't apply to claimant.

       1.   Marked restriction of activities of daily living. Ms. ___ has been diagnosed with
             anxiety disorder. As per Mayo Clinic: symptoms of this disorder are being anxious
             without reason. The patient's worries disrupt daily life. Generalized anxiety disorder
             causes excessive or unrealistic anxiety and worry--well beyond what's appropriate
             for a situation. These symptoms are as described by the patient.

      2.   Marked difficulties in maintaining social functioning: Ms. ___ doesn't want to go out
             of her home. She just wants to stay at home, not socialize with others; has feelings of
             being very nervous all of the time.

       3.   Marked difficulties in maintaining concentration, persistence, or pace; Ms. ___ has
             difficulty in maintaining concentration and in processing information; partly from the
             depression and anxiety, partly from the medications and their side effects and partly in
             her language barrier. Ms. ___ has been diagnosed with anxiety disorder. As per the
             Mayo Clinic, some of the symptoms of anxiety are: restlessness, difficulty concentrating,
             feeling "keyed up or on edge", and being easily distracted. These symptoms are as
             described by the patient.

       4.   Repeated episodes of decompensation (a loss of ability to maintain normal or
             appropriate psychological defenses, sometimes resulting in depression, anxiety or
             delusions), each of extended duration; has had Major Depression and Anxiety Disorder
             since 2004. Unable to follow up with___Mental Health. States that she wants to die.
  OR

       C. Medically documented history of a chronic affective disorder of at least 2 years' duration
             that has caused more than a minimal limitation of ability to do basic work activities, with
             symptoms or signs currently attenuated by medication or psychosocial support, and
             one of the following:

             1.    Repeated episodes of decompensation, (a loss of ability to maintain normal or
                    appropriate psychological defenses, sometimes resulting in depression, anxiety, or
                    delusions) each of extended duration; Claimant has diagnoses of Major depression
                    and Anxiety Disorder. Saw _______ Mental Health for these diagnoses, until she was
                    no longer able to pay. She needs routine follow-up for these diagnoses, especially in
                    the light of her symptoms of helplessness, hopelessness, worthlessness, inability to
                concentrate, sleep and appetite disturbances. Hopelessness precedes suicidal
                    thoughts and because there is no hope, one looses the will to live. Ms. _____ states
                    that she wants to die. She has been diagnosed with major depression since 5/11/ 2001
                    and anxiety disorder since 2003.

              2.   A residual disease process that has resulted in such marginal adjustment that even a
                    minimal increase in mental demands or change in the environment would be
                  predicted to cause the individual to decompensate; or

            3.   Current history of 1 or more years' inability to function outside a highly supportive
                    living arrangement, with an indication of continued need for such an arrangement. Ms.
                    _____ has been living for an extended period of time with her daughter, who assists in
                taking care of her.

If conditions are met for Step 3, it is not necessary to go to Step 4. These steps have
already been met. However, going on to #4.

Step Four: The Claimant’s residual functional capacity (20 CFR 416.920 (e)) has to be determined. The residual functional
capacity is her ability to do physical and mental work activities on a sustained basis despite limitations from her impairments.
Basically, can the claimant do the work that she did previously? By history, Ms. _____ has worked in different sewing factories
as a general laborer. As stated by Dr. _____, “By history, she has done manual type labor, and it appears that the claimant
appears to have marked limitations in the ability to do complex and detailed work. Ability to work with the public, concentrate
and adapt appears to be moderately limited. Certainly language could be a barrier.” He gave a diagnosis of borderline to low
average intellectual functioning.

Step Five: It is to be determined whether the claimant is able to do any other work considering her residual functional capacity,
age, education and work experience. 20 CFR 416.920 (g), states that if the claimant is not able to do other work and meets
the duration requirement, she is disabled.

Basically, her capabilities to perform the basic mental demands of unskilled work are so severely compromised that she cannot
engage in any activity on a regular basis for 8 hours/day and 5 days a week. (SSR 96-8p and 96-9p).

Thank you so much for allowing me to review this case. If I can be of further assistance, please let me know.

Carolyn Hartsell BSN, RN, CLNC
Hartsell & Associates Legal Nurse Consulting
Morristown, TN 37814-1465
423-587-2545

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