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Disabilities: Cervical strain, lumbar strain and sprain, herniated disc at L4-L5, somatic dysfunction of lumbar spine, degenerative joint disease of knees, status post left knee arthroscopy with residual pain and swelling, morbid obesity
Notice of Decision: Fully Favorable
Senior Attorney Advisor: Tammy A. Thames
Office of Disability Adjudication & Review (ODAR): Broward County, Florida & Palm Beach County, Florida
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, 2011.
2. The claimant has not engaged in substantial gainful activity since June 2, 2006, the amended alleged onset date (20 CFR 404.1520(b), 404.1571 et seq., 416.920(b) and 416.971 et seq.).
3. The claimant has the following severe impairment(s): cervical strain, lumbar strain and sprain, herniated disc at L4-L5, somatic dysfunction of lumbar spine, degenerative joint disease of knees, status post left knee arthroscopy with residual pain and swelling, morbid obesity (5 feet 6 ½ inches tall, weight of 282 pounds), and depression (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. After careful consideration of the entire record, the undersigned finds that the claimant has the residual functional capacity to perform the full range of sedentary work as defined in 20 CFR 404.1567(a) and 416.967(a).
The claimant has the following degree of limitation in the broad areas of functioning set out in the disability regulations for evaluating mental disorders and in the mental disorders listings in 20 CFR, Part 404, Subpart P, Appendix I: mild restriction of activities of daily living; mild difficulties in maintaining social functioning; moderate difficulties in maintaining concentration, persistence or pace; and no episodes of decompensation.
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 of20 CFR 404.1529 and 416.929 and SSRs 96-4p 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, 96-5p, 96-6p and 06-3p.
On May 8, 2006, Dr. Dennis B. Zaslow, D.O., who is an orthopedic surgeon, performed an initial evaluation of the claimant. Ms. Bengochea presented with complaints of left knee pain, which she rated as 8 to 9, and lower back pain, which she rated as 9, on a scale of 0 to 10, with 10 being the most severe. She related to Dr. Zaslow that her pain radiates up to her shoulders and cervical spine, occasionally associated with headaches and dizziness. The claimant described feeling as though her mid back was separating; she stated that she experienced exacerbations of pain that could last up to 5 hours at a time. Dr. Zaslow reviewed an MRI of the claimant's lumbar spine, which was performed on December 30, 2005, and it showed far left lateral herniated disc at L4-L5, extending into the left L4-L5 foramina leading to minimal left-sided foraminal encroachment. He noted that Ms. Bengochea's scan demonstrated degenerative changes in the popliteal joint at L3-L4. Dr. Zaslow reported that the claimant weighed 250 pounds, at 5 feet 7 inches tall. He observed that Ms. Bengochea was unable to fully hyperextend the back and unable to fully squat. The claimant had some tenderness over the left and right SI notch. Dr. Zaslow's examination further revealed tenderness over the medial border of the claimant's left and right scapula. Examination of Ms. Bengochea's left knee revealed slight swelling and tenderness over the porthole, as well as pain along the medial joint fissure. Dr. Zaslow observed that the claimant ambulated with a left-sided degree of limp.
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Awarded: Confidential