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Disabilities: Cervical spine congenital canal stenosis with cord compression; bilateral neural foraminal stenosis; lumbar spondylosis; lumbar radiculopathy; herniated lumbar disc status post-lumbar discectomy; carpal tunnel syndrome; atelectasis; cardiomegaly; recurrent migraine headaches; depression; and obesity
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, I make the following findings:
1. The claimant has not engaged in substantial gainful activity since September 17, 2005, the established onset date (20 CFR 416.920(b) and 416.971 et seq.).
2. The claimant has the following severe impairments: Cervical spine congenital canal stenosis with cord compression; bilateral neural foraminal stenosis; lumbar spondylosis; lumbar radiculopathy; herniated lumbar disc status post-lumbar discectomy; carpal tunnel syndrome; atelectasis; cardiomegaly; recurrent migraine headaches; depression; and obesity.
3. The severity of the claimant's impairments medically equal the criteria of section 1.04C of 20 CFR Part 404, Subpart P, Appendix 1 (20 CFR 416.920(d)).
In making this finding, I 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 416.929 and SSRs 96-4p and 96-7p. I have also considered opinion evidence in accordance with the requirements of 20 CFR 416.927 and SSRs 96-2p, 96-6p and 06-3p.
The claimant is a 50-year-old female with an 11th grade education. She is 5'5" and weighs 230 pounds. She has been prescribed Fentanyl, Percocet, Skelaxin, Imitrex, Naproxen, Nexium, Carisoprodol, and Meloxicam for treatment of her chronic conditions. In addition, the claimant has been prescribed a cane, neck brace, back brace, and two hand braces.
An MRI of the claimant's cervical spine dated March 3, 2005, revealed multilevel cervical spondylosis causing canal stenosis, cord compression, and signal abnormality at C5-6 (Exhibit l7F/114). Treatment notes dated September 8, 2006, from Orthopedic Health and Rehabilitation Centers, confirmed the claimant had a severely restricted range of motion of the lumbar spine; positive straight-leg raising tests; and lower back pain radiating to the right buttock. (Exhibit 7F). The diagnoses in these records also included lumbar radiculopathy, lumbar sprain and strain, and lumbar somatic dysfunction.
Treatment notes dated October 13, 2006, from Dennis Zaslow, D.O., confirmed the claimant had lumbar radiculopathy (Exhibit 23F), Dr. Zaslow stated the claimant's "radicular problems are worse on the right side." Moreover, Dr. Zaslow stated that her pain "goes into her leg while crossing the right buttock." Dr. Zaslow concluded the claimant had tingling all the way to her toes, an inability to extend her trunk more than a few degrees, and an inability to squat. Dr. Zaslow examined the claimant on January 18, 2007, and concluded that she was unable to forward flex her lumbar spine past 30 degrees; she could not hyperextend her back; her rotation bilaterally was restricted; she was unable to squat; and the straight-leg raising from the seated position on the right side increased her symptoms at 40 degrees. Dr. Zaslow opined that the claimant was to avoid excessive bending, lifting, pushing, and pulling.
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