Worked at Shopright. Had to stop do to numbness in leg on right side when waling or standing
Found no severe impairments
Ordered ALJ to reconsider total record
RFC for Sedentary work involving simple/routine tasks characteristic of unskilled work
Remand following a Remand order from the US District Court of EDP. Failed to follow directions of SSR 02-01p and analyze effect of obesity on claimants other impairments
1) L2-3 bulge, facet arthopathy, Spinal Stenosis
2) L3-4 & L4-5 desiccation, no herniation or spinal stenosis
Disc dessication at L2-3 with broad based disc protrusion and a right paracentral disc herniation focally compressing the thecal sac anteriorly.
At L3-4 there is disc dessication without stenosis
At L4-5 disc dessication with broad based disc protrusion and a right paracentral to foraminal disc herniation with hypertrophic changes of the facets and ligamentum flavum resulting in focal compression of the thecal sac anteriorly on the right. Possible impingment of the r. L5 nerve root and bilateral foraminal stenosis.
Impression: Myxoid degeneration posterior horn medial meniscus inflamed anterior cruciate ligament. Soft tissue edema involving the soft tissues of the knee with some prepateller edema.
Revealed: moderate left anterior tibial artery disease and mild left posterior tibial artery disease.
Physical Exam reveals obese (289lbs) female. Pain on full extension, markedly positive patellar inhibition sign, mild pain on McMurray's. MRI of r. knee reveals question of inflamed ACL. He injected her knee, and reccommened PT if pain continious .
Impression: Chondromalacia patella right knee.
Notes: pain severe when walking, laying, bending, climbing. Walking with Cane, right knee gives out fall.
Recently fell and twisted her left ankle and is complaining of pain in right calf. Physical exam shows positive patellar inhibition, pain on full extension, complaints of posterior knee pain. PT is recommended, weight loss is essential.
Reveals minor to moderate degenerative changes
Based on Diabetes/anxiety/hierria/depression/back/neck pinched nerve/
Lift Carry- Less than 10lbs
Standing Walking- Less than 2 hours
Sitting- Less than 6 hours
Never Stooping or other postural activities
sitting: 15 minutes/time & 5 hours total
standing/walking: 15 minutes, then must LIE DOWN for 30 Minutes
Standing Walking: 2 hours of 8
Must lie down for 5 hours during the course of the day
Should do no lifiting
Based on DJD, DDD, Knee Pain
Bilateral Calceneal spurs
Positive for neuropathy, burning, pain
Positive for neuropathy & foot pain
11/8/2006 :Echocardiogram/Doppler revealed left ventricular diastolic noncompliance with mild mitral and tricuspid regurgitation.
Doesn't seem to be a big issue.