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Disabilities: Right leg fracture and degenerative disc disease.
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, 2008.
2. The claimant has not engaged in substantial gainful activity since March 11, 2007, the alleged onset date (20 CFR 404.1520(b), 404.1571 et seq.; 416.920(b) and 416.971 et seq.).
The claimant worked after the established disability onset date, but this work activity did not rise to the level of substantial gainful activity.
3. The claimant has the following severe impairments: right leg fracture and degenerative disc disease. (20 CFR 404.1520(c) and 416.920(c)).
4. The claimant does not have an impairment or combination of impairments that meets or medically equals one of the listed impairments in 20 CFR Part 404, SUbpart P, Appendix 1 (20 CFR 404.1520(d) and 416.920(d)).
5. The claimant has the residual functional capacity to perform sedentary work as defined in 20 CFR 404.1567(a) and 416.967(a) except he can lift and carry less than 10 pounds frequently or occasionally, can sit for less than 6 hours in an 8 hour workday, and can stand/walk for less than 2 hours in an 8 hour workday
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 CFR404.1529 and 416.929 and SSRs96-4p 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 claimant suffered a complex open right mid shaft tibial fracture with significant soft tissue injury in March 2007 and underwent open reduction internal fixation of the right tibia with four compartment faciotomy. His hospital course was complicated by persistent swelling in the right lower extremity, multiple trips to the OR were made to maintain local wound care. He was hospitalized approximately a month later with diffuse swelling from the knee to the toes and open wound with surrounding erythema and some necrotic tissue, leading to the performance of debridement with split thickness skin graft. MRl of the lumbar spine conducted in July 2008 revealed posterior central and left sided shallow broad based herniated protrusion at L5-S1 extending into the left foramen slightly deforming the duralsac and approaching the course of the left L5 nerve root without stenosis, facet hypertrophy, and disc space narrowing with degenerative endplate marrow change and anterior spondylosis on the left, along with disc bulging at L4-5 deforming the dural sac with prominent facets, and bulging at L2-3 with mild retrolisthesis disc narrowing, Schmorl's node formation, and anterior spondylosis along with posterior bulging at L1-2 with narrowing and spondylosis and anterior and posterior bulging at T11-12.
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