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Disabilities: s/p L5-S1 laminectomy, degenerative disc disease, major depressive disorder, anxiety, and borderline intellectual functioning.
Notice of Decision: Fully Favorable
Administrative Law Judge: (Insert Judge's Name)
Office of Disability Adjudication & Review (ODAR): (Insert Name of Hearing Office)
FINDINGS OF FACT AND CONCLUSIONS OF LAW
After careful consideration of the entire record, the undersigned makes the following findings:
1. The claimant's date last insured is September 30, 2011.
2. The claimant has not engaged in substantial gainful activity since August 1, 2006. the alleged onset date (20 CFR 404.1520(b). 404.1571 et seq., 416.920(b) and 416.971 et seq.).
3. The claimant has the following severe impairment(s): s/p L5-S1 laminectomy, degenerative disc disease, major depressive disorder, anxiety, and borderline intellectual functioning. (20 CFR 404.1520(c) and 416.920(c)).
4. The severity of the claimant's impairments meets the criteria of section 12.04 A (1) with (a),(c),(f),(h) AND 12.04 B (1) and (2) of 20 CFR Part 404, Subpart P, Appendix 1 (20 CFR 404.1520(d) and 416.920(d)).
In making this finding, the undersigned considered all symptoms and the extent to which these symptoms can reasonably be accepted as consistent with the objective medical evidence and other evidence, based on the requirements of 20 CFR 404.1529 and 416.929 and SSRs 96-4p and 96-7p. The undersigned has also considered opinion evidence in accordance with the requirements of 20 CFR 404.1527 and 416.927 and SSRs 96-2p, 96-6p and 06-3p.
The records of Dr. Harold Schwartz, psychiatrist, of August 15, 2007 indicate the claimant presented with complaint of disorganized thinking and of being frequently tearful, along with a suicidal ideation. His mood was found to be depressed and his affect tearful but appropriate to thought Insight and concentration were fair. He advised that he had been jailed in 2005 for 3 1/2 months on a charge of cocaine possession, and reported abstinence from drugs and alcohol for the prior 4 month period. Diagnosis was of Major Depression, recurrent and chronic with anxiety, and polysubstance abuse and dependence in remission. Dr. Schwartz also opined the claimant was at risk for worsening of his symptoms, because he was, "so depressed and stressed". The medication Cymbalta was prescribed. (Ex. 11F)
On August 9, 2007, the claimant underwent an independent medical evaluation by Dr. Rafael Seminario, He reported that since an earlier work injury, he was depressed, sad, and despondent, and was always exhausted in the mornings as he was unable to sleep at night due to pain. In addition, he reported a decrease in interest in life and hobbies and because of a decrease in appetite, had lost ten pounds. He also reported he was angry and nasty towards his wife and family members, has a history of aggressive thoughts, and has felt helpless and hopeless at times. Finally, he had thoughts of hurting himself by running in front of a car.
Upon exam, Dr. Seminario found his mood was angry and fiustrated, his affect was appropriate, but that his judgment and insight were only fair, He also felt the claimant's ability to care for himself was fair. Diagnosis was of Major Depressive Disorder and a Pain disorder. Finally, Dr. Seminario felt he would benefit from psychiatric treatment. (Ex. 6F)
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