Tracy L.

Main

MVA

7/12/11

Unrestrained passenger in a MVA, Her car was rear ended and she was thrown forward.

Jurisdictional

AOD

1/1/09

Listed as Affective/Mood Disorders & Anxiety Disorders at Onset

PFD

9/28/10

SSI & SSD

SGA

1/1/2011

She is still working, but get clarification on last date worked full time.

Initial Denial

6/7/2011

RFC assessed at all exertional levels, with non-exertional restrictions including limitation to unskilled work

Sarcoidosis

SC: SOB (4F)

1/9/10 - 1/10/10

Reported shortness of breath

Progress Report From Temple Lung Center

11/8/11 - 11/9/11

Notes: Complained of SOB for 2 years, associated with cough and clear phlem. Shortness of breath with minimal exertion.

Assessment: Sarcoidosis, clinical stage 2, biopsy proven

Plan: Start prednisone 30mg, renal evaluation for kidney, pulmonary testing and CT of chest 3-6 months.

Prognosis- May need lifelong anticoagulations due to positive factor V Leiden

Interstitial Emphysema

Mental Health

Inpatient at Friends Hospital

8/25/10 - 8/31/10

Daughter thought she would hurt herself following suicide of fiance. She did have suicidal ideation.

DX: Major Depressive DO, Severe, Recurrent; Generalized Anxiety DO.

GAF on Admission= 10, on Discharge= 50

Husbands Suicide

8/25/10

Intake Assessment At JFK (5F)

9/8/10 - 9/9/10

Depressed, no sleep, no appetite, mild paranoia, pressured speech,

DX: Major Depressive DO, Anxiety DO, R/O Borderline personality DO GAF 55

Deep vein Thrombosis

Back Pain

MRI of L. Shoulder & Cervical Spine (1F)

5/5/03 - 5/6/03

MRI of Left Shoulder: Mild acromioclavicular osteoarthritis

MRI of Thoracic Spine (1F)

5/4/04 - 5/5/04

Mild disc desiccation at T9-10

MRI of Lumbar Spine

7/12/11 - 7/13/11

Impression: L4-5: Traverse and AP spinal stenosis with associated disc dessication and disc bulge causing ventral thecal sac, lateral recess enchroachment

Cervical MRI

7/12/11 - 7/13/11

Impression: Muscle Spasms

Progress Note- Gene Levinstein, M.D.,

2/28/12 - 2/29/12

Offers Dx, notes positive ortho testing, orders EMG,

EMG of Lower Extremities (Normal)

3/14/12 - 3/15/12

For complaints of persistent lower back pain which radiates into the lower extremities with tingling and numbness in the feet and the toes.

Results: NORMAL

Brachial Plexopathy

Neuropathy

Radiculopathy