Secondary Diagnosis: Affective Disorders Case Study
Secondary diagnosis: Affective disorders.
The claimant was a 43-year-old man.
Alleged disability: right and left leg injury.
He reported that he had mobility limitations because of bilateral lower extremity pain and lack of strength; he could not stand for a prolonged period, and ambulated with crutches. He had difficulty with some activities of daily living (ADLs). He had difficulty understanding and following directions as well as trouble with memory, concentration, and completing tasks. He needed reminders.
Education: third grade, Spanish language, but illiterate.
Work experience: agriculture (1988-1993), and cook (pizza business (1996-2001).
The Comparison Point Decision (CPD) date was 11/18/2005.
Per medical records and consultative …show more content…
He was irritable, had poor stress tolerance, was frustrated, and hopeless. He did not want to live with the pain and limitations he had. His insight and judgment were poor. He did not cooperate with the evaluation of memory, attention, and concentration. He was diagnosed with, major depressive …show more content…
The primary diagnosis was fractures of lower limb. The secondary diagnosis was affective disorders.
The medical records and consultative examinations (CE) (2015) supported the claimant’s disability allegations. He still ambulated with crutches, had limited range of motion, chronic pain, and depression. He had a “serious impairment in occupational functioning.” He was unable to work in his field. His prognosis was poor.
There was no medical improvement in the claimant’s condition.
Per medical records and consultative examination (CE) (2015), the claimant had an abnormal gait, was not able to stand up straight, ambulated with crutches, was unable to stand on one leg and then the other, and was able to stand on the left foot, but complained of pain. Had had limited range of motion (ROM) of the neck, shoulders, hips, lower back, and ankles. Radiological studies showed posttraumatic changes, surgical changes (including hardware) of the left femur, right and left foot that caused deformities, and degenerative changes of the right ankle. The diagnoses listed included right ankle post-traumatic arthritis, right temporomandibular joint dysfunction, status post fracture and surgical treatment of bilateral lower extremities, chronic pain, and generalized anxiety
The claimant was a 43-year-old man.
Alleged disability: right and left leg injury.
He reported that he had mobility limitations because of bilateral lower extremity pain and lack of strength; he could not stand for a prolonged period, and ambulated with crutches. He had difficulty with some activities of daily living (ADLs). He had difficulty understanding and following directions as well as trouble with memory, concentration, and completing tasks. He needed reminders.
Education: third grade, Spanish language, but illiterate.
Work experience: agriculture (1988-1993), and cook (pizza business (1996-2001).
The Comparison Point Decision (CPD) date was 11/18/2005.
Per medical records and consultative …show more content…
He was irritable, had poor stress tolerance, was frustrated, and hopeless. He did not want to live with the pain and limitations he had. His insight and judgment were poor. He did not cooperate with the evaluation of memory, attention, and concentration. He was diagnosed with, major depressive …show more content…
The primary diagnosis was fractures of lower limb. The secondary diagnosis was affective disorders.
The medical records and consultative examinations (CE) (2015) supported the claimant’s disability allegations. He still ambulated with crutches, had limited range of motion, chronic pain, and depression. He had a “serious impairment in occupational functioning.” He was unable to work in his field. His prognosis was poor.
There was no medical improvement in the claimant’s condition.
Per medical records and consultative examination (CE) (2015), the claimant had an abnormal gait, was not able to stand up straight, ambulated with crutches, was unable to stand on one leg and then the other, and was able to stand on the left foot, but complained of pain. Had had limited range of motion (ROM) of the neck, shoulders, hips, lower back, and ankles. Radiological studies showed posttraumatic changes, surgical changes (including hardware) of the left femur, right and left foot that caused deformities, and degenerative changes of the right ankle. The diagnoses listed included right ankle post-traumatic arthritis, right temporomandibular joint dysfunction, status post fracture and surgical treatment of bilateral lower extremities, chronic pain, and generalized anxiety