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This piece is a sample case result that an attorney may benefit from on their legal website.
DISCLAIMER: Please note that every case is different and these verdicts and settlements, while accurate, do not represent what we may obtain for you in your case.
Disabilities: Chronic Severe Pain, Fibromyalgia and Major Depressive Disorder
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 December 31, 2011.
2. The claimant has not engaged in substantial gainful activity since March 1, 2006, the alleged onset date (20 CFR 404.1520(b) and 404.1571 et seq.).
3. The claimant has the following severe impairment(s): Chronic Severe Pain, Fibromyalgia and Major Depressive Disorder (20 CFR 404.1520(c)).
4. The severity of the claimant's impairments meets the criteria of section 12.04 A (1) a, c, d, e, g, h, & i and B (1) (2) & (3) and C (2) of 20 CFR Part 404, Subpart P, Appendix 1 (20 CFR 404.1520(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 SSRs 96-4p and 96-7p. The undersigned has also considered opinion evidence in accordance with the requirements of 20 CFR 404.1527 and SSRs 96-2p, 96-6p and 06-3p.
The claimant's impairments meet listing 12.04 A (1) a, c, d, e, g, h, & i and B (1) (2) & (3) and C (2).
The medical record demonstrates that the claimant has chronic complaints, not only of back pain and fibrornyalgia, but of depression. The claimant sustained an injury at work on May 17, 2005. There was a fire alarm going off and she was running backwards with a cart. She collided with an open door and hit her lower back. Initially she was seen by the doctor at the Workers' Compensation Clinic. She was then referred by Dr. Seth Hochman (Exhibit 1F), who in turn referred her to Dr. Pagan. The claimant received treatment of her orthopedic symptoms from Luis R. Pagan, M.D., a board certified neurologist, from July 11, 2005 through February 27, 2006. He diagnosed the claimant with arthritis and he began treating her with physical therapy and pain medications (Exhibit 3F & 17F). The progress notes from Analays M. Ballesteros, D.O., reflect treatment from January 18, 2006 through January 12, 2009 (Exhibit 7F, 16F & 25F). Dr. Ballesteros referred the claimant Antonio Mesa, D. O. for pain management and interventional neurology on February 28, 2006 (Exhibit 4F). Dr. Mesa reported the claimant's chief complaints were headaches, back and leg pain. Dr. Mesa's impressions of the claimant's symptoms on this date were noted as: Headaches, Cervical Dystonia, Low Back Pain, Myofascial Pain Syndrome, Muscle Spasms and Scoliosis (Exhibit 4F, pg. 6).
Peter J. Millheiser, M.D., examined the claimant and performed a consultative evaluation on May 9, 2006. He reached a diagnosis of Cervical Sprain, Thoracic Sprain and Lumbar Sprain (Exhibit 5F, pgs. 1 & 2).
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